Provider Demographics
NPI:1891390746
Name:SRINIVASAN, SENTHIL RAJ
Entity type:Individual
Prefix:
First Name:SENTHIL RAJ
Middle Name:
Last Name:SRINIVASAN
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 1:5208 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-2208
Mailing Address - Country:US
Mailing Address - Phone:317-486-9667
Mailing Address - Fax:317-486-9678
Practice Address - Street 1:5208 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-2208
Practice Address - Country:US
Practice Address - Phone:317-486-9667
Practice Address - Fax:317-486-9678
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022043A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist