Provider Demographics
NPI:1912334343
Name:SRISIRI PHARMA INC
Entity type:Organization
Organization Name:SRISIRI PHARMA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:KHAJENDRANATH
Authorized Official - Middle Name:
Authorized Official - Last Name:ATLURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-953-2331
Mailing Address - Street 1:190 HADSELL DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0408
Mailing Address - Country:US
Mailing Address - Phone:248-953-2331
Mailing Address - Fax:313-447-1688
Practice Address - Street 1:2255 FORT ST
Practice Address - Street 2:INDEX PARK PHARMACY
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2671
Practice Address - Country:US
Practice Address - Phone:313-357-7500
Practice Address - Fax:313-347-8998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
MI53010102023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2378405OtherNCPDP