Provider Demographics
NPI:1508461906
Name:SAMBARAJU, SRINIVAS
Entity Type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:
Last Name:SAMBARAJU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3529 CARDINAL WAY
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8379
Mailing Address - Country:US
Mailing Address - Phone:612-270-1349
Mailing Address - Fax:
Practice Address - Street 1:3705 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221-2703
Practice Address - Country:US
Practice Address - Phone:317-856-1253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17669183500000X
IN26022672A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist