Provider Demographics
NPI:1194309575
Name:RAVI, SHRUTHI
Entity type:Individual
Prefix:
First Name:SHRUTHI
Middle Name:
Last Name:RAVI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11054 63RD DR
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1408
Mailing Address - Country:US
Mailing Address - Phone:347-935-8006
Mailing Address - Fax:
Practice Address - Street 1:310 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:PA
Practice Address - Zip Code:18014-1025
Practice Address - Country:US
Practice Address - Phone:610-837-9992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP455586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist