Provider Demographics
NPI:1902203474
Name:SRIDHARA, SHASHANK (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHASHANK
Middle Name:
Last Name:SRIDHARA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8805 CITRUS VILLAGE DR APT 207
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-3688
Mailing Address - Country:US
Mailing Address - Phone:941-914-5045
Mailing Address - Fax:
Practice Address - Street 1:8805 CITRUS VILLAGE DR APT 207
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-3688
Practice Address - Country:US
Practice Address - Phone:941-914-5045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-29
Last Update Date:2014-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS52825OtherDEPARTMENT OF HEALTH