Provider Demographics
NPI:1497003370
Name:TAVISALA, SRILATHA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SRILATHA
Middle Name:
Last Name:TAVISALA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 SW BOND AVE
Mailing Address - Street 2:530
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4706
Mailing Address - Country:US
Mailing Address - Phone:503-343-9845
Mailing Address - Fax:
Practice Address - Street 1:7700 NE AMBASSADOR PL
Practice Address - Street 2:103
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-1394
Practice Address - Country:US
Practice Address - Phone:971-230-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-26
Last Update Date:2012-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0013282183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist