Provider Demographics
NPI:1225164189
Name:KORELLA, SRIDHAR (BS)
Entity Type:Individual
Prefix:
First Name:SRIDHAR
Middle Name:
Last Name:KORELLA
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3457 LAUREL LEAF DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065
Mailing Address - Country:US
Mailing Address - Phone:904-699-2404
Mailing Address - Fax:
Practice Address - Street 1:11101 ST AUGUSTINE ROAD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065
Practice Address - Country:US
Practice Address - Phone:904-260-9755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist