Provider Demographics
NPI:1639507296
Name:SRIKANTAIAH, SHIVAKUMAR
Entity Type:Individual
Prefix:
First Name:SHIVAKUMAR
Middle Name:
Last Name:SRIKANTAIAH
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 1:816 AUTUMN GLEN DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6423
Mailing Address - Country:US
Mailing Address - Phone:321-752-9125
Mailing Address - Fax:
Practice Address - Street 1:816 AUTUMN GLEN DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-6423
Practice Address - Country:US
Practice Address - Phone:321-752-9125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37173183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist