Provider Demographics
NPI:1861005621
Name:SAMPATHKUMAR, BALAKA
Entity Type:Individual
Prefix:
First Name:BALAKA
Middle Name:
Last Name:SAMPATHKUMAR
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 1:5475 MURRELL RD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6665
Mailing Address - Country:US
Mailing Address - Phone:321-631-3732
Mailing Address - Fax:
Practice Address - Street 1:5475 MURRELL RD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-6665
Practice Address - Country:US
Practice Address - Phone:321-631-3732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-30
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS60213183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist