Provider Demographics
NPI:1417290487
Name:KAMMILA, SRIRAM (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:SRIRAM
Middle Name:
Last Name:KAMMILA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 BRITTANY LN NE
Mailing Address - Street 2:APARTMENT NUMBER G105
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5778
Mailing Address - Country:US
Mailing Address - Phone:916-214-5866
Mailing Address - Fax:
Practice Address - Street 1:8230 MARTIN WAY EAST
Practice Address - Street 2:RITE AID
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-5778
Practice Address - Country:US
Practice Address - Phone:360-456-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60318273183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist