Provider Demographics
NPI:1659095396
Name:PANUGANTI, SRIDEVI
Entity Type:Individual
Prefix:
First Name:SRIDEVI
Middle Name:
Last Name:PANUGANTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 BRIARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:COLMAR
Mailing Address - State:PA
Mailing Address - Zip Code:18915-3101
Mailing Address - Country:US
Mailing Address - Phone:570-236-7112
Mailing Address - Fax:
Practice Address - Street 1:650 W CUTHBERT BLVD
Practice Address - Street 2:
Practice Address - City:HADDON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08108-3642
Practice Address - Country:US
Practice Address - Phone:856-833-1710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04095300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist