Provider Demographics
NPI:1013513043
Name:JOSE, SRUTHY
Entity type:Individual
Prefix:
First Name:SRUTHY
Middle Name:
Last Name:JOSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6512 SAND LAKE SOUND RD APT NO2311
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7499
Mailing Address - Country:US
Mailing Address - Phone:813-453-2693
Mailing Address - Fax:
Practice Address - Street 1:6790 CENTRAL FLORIDA PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32821-6025
Practice Address - Country:US
Practice Address - Phone:407-238-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS61091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist