Provider Demographics
NPI:1255605820
Name:BALASUBRAMANYAN, SRIDHAR (RPH, PHD)
Entity type:Individual
Prefix:DR
First Name:SRIDHAR
Middle Name:
Last Name:BALASUBRAMANYAN
Suffix:
Gender:M
Credentials:RPH, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 E NOB HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-3534
Mailing Address - Country:US
Mailing Address - Phone:509-249-0477
Mailing Address - Fax:509-457-3867
Practice Address - Street 1:602 E NOB HILL BLVD
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-3534
Practice Address - Country:US
Practice Address - Phone:509-249-0477
Practice Address - Fax:509-457-3867
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00071904183500000X
WAPH000719041835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist