Provider Demographics
NPI:1861811549
Name:SRISAI RX MART LLC
Entity type:Organization
Organization Name:SRISAI RX MART LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONNALGADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-494-0458
Mailing Address - Street 1:304 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LE ROY
Mailing Address - State:IL
Mailing Address - Zip Code:61752-1679
Mailing Address - Country:US
Mailing Address - Phone:309-962-3627
Mailing Address - Fax:309-962-3122
Practice Address - Street 1:304 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LE ROY
Practice Address - State:IL
Practice Address - Zip Code:61752-1679
Practice Address - Country:US
Practice Address - Phone:309-962-3627
Practice Address - Fax:309-962-3122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054014379333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145186OtherPK