Provider Demographics
NPI:1639679079
Name:JAI JAGANNATH INC
Entity Type:Organization
Organization Name:JAI JAGANNATH INC
Other - Org Name:SUNNYVALE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SRINIVASA RAO
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMIRISETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-290-0341
Mailing Address - Street 1:3635 N BELT LINE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75182-9235
Mailing Address - Country:US
Mailing Address - Phone:972-290-0341
Mailing Address - Fax:972-290-0351
Practice Address - Street 1:3635 N BELT LINE RD STE 100
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-9235
Practice Address - Country:US
Practice Address - Phone:972-290-0341
Practice Address - Fax:972-290-0351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX318513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy