Provider Demographics
NPI:1790316453
Name:GADDIPATI, SRIDHAR
Entity Type:Individual
Prefix:
First Name:SRIDHAR
Middle Name:
Last Name:GADDIPATI
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 1:51007 DAROCA CT
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-4210
Mailing Address - Country:US
Mailing Address - Phone:734-612-6431
Mailing Address - Fax:
Practice Address - Street 1:15640 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3734
Practice Address - Country:US
Practice Address - Phone:313-584-0808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037554183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist