Provider Demographics
NPI:1144645821
Name:PONNADA, SRIKANTH
Entity type:Individual
Prefix:
First Name:SRIKANTH
Middle Name:
Last Name:PONNADA
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 1:1933 LEANNE DR
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4490
Mailing Address - Country:US
Mailing Address - Phone:541-314-3271
Mailing Address - Fax:575-887-8300
Practice Address - Street 1:808 N CANAL ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-2418
Practice Address - Country:US
Practice Address - Phone:575-887-5085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7444183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61512Medicaid