Provider Demographics
NPI:1942547914
Name:TALLAVAJHALA, SIVA NARAYAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:SIVA
Middle Name:NARAYAN
Last Name:TALLAVAJHALA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 MARTEN RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-1634
Mailing Address - Country:US
Mailing Address - Phone:732-423-1166
Mailing Address - Fax:973-556-1472
Practice Address - Street 1:603 MARTEN RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-1634
Practice Address - Country:US
Practice Address - Phone:732-423-1166
Practice Address - Fax:973-556-1472
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03362000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist