Provider Demographics
NPI:1790047744
Name:THOTA, SRINIVASULU
Entity Type:Individual
Prefix:MR
First Name:SRINIVASULU
Middle Name:
Last Name:THOTA
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 1:563 BROAD ST
Mailing Address - Street 2:VALUE PLUS PHARMACY
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-4503
Mailing Address - Country:US
Mailing Address - Phone:973-623-5566
Mailing Address - Fax:973-623-7144
Practice Address - Street 1:563 BROAD ST
Practice Address - Street 2:VALUEPLUS PHARMACY
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07901
Practice Address - Country:US
Practice Address - Phone:973-623-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00606300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist