Organization
SRISAI RX MART LLC
Active
Other names
Leroy Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
SIVA JONNALGADA (MANAGER)
(732) 494-0458
Entity
Organization
Contact information
Practice address
304 SUNSET DR, LE ROY, IL 61752-1679
(309) 962-3627
(309) 962-3122
Mailing address
304 SUNSET DR, LE ROY, IL 61752-1679
(309) 962-3627
(309) 962-3122
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
Primary
054014379
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2145186
PK
—
Enumeration date
04/10/2014
Last updated
04/10/2014
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