Provider Demographics
NPI:1215203583
Name:MADDALI, SRINIVAS
Entity type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:
Last Name:MADDALI
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 1:1 CATHER CT
Mailing Address - Street 2:
Mailing Address - City:LEDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07852-2313
Mailing Address - Country:US
Mailing Address - Phone:973-584-6465
Mailing Address - Fax:
Practice Address - Street 1:1 CATHER CT
Practice Address - Street 2:
Practice Address - City:LEDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07852-2313
Practice Address - Country:US
Practice Address - Phone:973-584-6465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041981183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist