Provider Demographics
NPI:1093007775
Name:EDARA, SUMANTH KUMAR (RPH)
Entity Type:Individual
Prefix:MR
First Name:SUMANTH
Middle Name:KUMAR
Last Name:EDARA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5452 BLANDING BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244
Mailing Address - Country:US
Mailing Address - Phone:904-779-6990
Mailing Address - Fax:904-779-6995
Practice Address - Street 1:5452 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244
Practice Address - Country:US
Practice Address - Phone:904-779-6990
Practice Address - Fax:904-779-6995
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5705314OtherNABP
FL1609166198OtherNPI