Provider Demographics
NPI:1275821134
Name:TIRUMALA PHARMACY INC
Entity Type:Organization
Organization Name:TIRUMALA PHARMACY INC
Other - Org Name:MEDPLEX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SIVARAMAKRISHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KONDAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-878-7615
Mailing Address - Street 1:4106 W LAKE MARY BLVD
Mailing Address - Street 2:#130
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3315
Mailing Address - Country:US
Mailing Address - Phone:407-878-7615
Mailing Address - Fax:407-878-7616
Practice Address - Street 1:4106 W LAKE MARY BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3383
Practice Address - Country:US
Practice Address - Phone:407-878-7615
Practice Address - Fax:407-878-7616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-13
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH255633336C0003X
3336C0004X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5706582OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5706582OtherNCPDP PROVIDER IDENTIFICATION NUMBER