Provider Demographics
NPI:1578804902
Name:KOLLA, VENU GOPAL
Entity Type:Individual
Prefix:
First Name:VENU GOPAL
Middle Name:
Last Name:KOLLA
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 1:212 TADCASTER CT
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7256
Mailing Address - Country:US
Mailing Address - Phone:904-735-5333
Mailing Address - Fax:
Practice Address - Street 1:212 TADCASTER CT
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-7256
Practice Address - Country:US
Practice Address - Phone:904-735-5333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41338183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist