Provider Demographics
NPI:1699101212
Name:YANNAM, SRINIVASA REDDY (MS PHARMACY)
Entity type:Individual
Prefix:
First Name:SRINIVASA
Middle Name:REDDY
Last Name:YANNAM
Suffix:
Gender:M
Credentials:MS PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:963 MAIN ST
Mailing Address - Street 2:APT 1A
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5145
Mailing Address - Country:US
Mailing Address - Phone:347-443-7875
Mailing Address - Fax:
Practice Address - Street 1:2262 WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-1302
Practice Address - Country:US
Practice Address - Phone:718-733-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057640-1183500000X
CTPCT.0011922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist