Provider Demographics
NPI:1740568773
Name:IVATURI, SRINIVASA V PRASAD (RPH)
Entity Type:Individual
Prefix:
First Name:SRINIVASA V PRASAD
Middle Name:
Last Name:IVATURI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:PRASAD
Other - Middle Name:SV
Other - Last Name:IVATURI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:136 CYPRUS LN
Mailing Address - Street 2:
Mailing Address - City:COATESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19320-4547
Mailing Address - Country:US
Mailing Address - Phone:215-688-2733
Mailing Address - Fax:856-935-4900
Practice Address - Street 1:228 E BROADWAY
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NJ
Practice Address - Zip Code:08079-1108
Practice Address - Country:US
Practice Address - Phone:856-935-4800
Practice Address - Fax:856-935-4900
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03424500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist