Provider Demographics
NPI:1952074494
Name:SRIVASTAVA, ILA (PHARMD)
Entity Type:Individual
Prefix:
First Name:ILA
Middle Name:
Last Name:SRIVASTAVA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 MERCANTILE DR E APT 108
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-7613
Mailing Address - Country:US
Mailing Address - Phone:425-289-6314
Mailing Address - Fax:
Practice Address - Street 1:6420 MERCANTILE DR E APT 108
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-7613
Practice Address - Country:US
Practice Address - Phone:425-289-6314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist