Provider Demographics
NPI:1396167342
Name:KANNAMALA, AJI
Entity type:Individual
Prefix:
First Name:AJI
Middle Name:
Last Name:KANNAMALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:WINN-DIXIE
Other - Middle Name:
Other - Last Name:PHARMACY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1145 HOMESTEAD RD N
Mailing Address - Street 2:LEHIGH ACRES
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-6039
Mailing Address - Country:US
Mailing Address - Phone:239-368-2100
Mailing Address - Fax:239-368-2289
Practice Address - Street 1:1145 HOMESTEAD RD
Practice Address - Street 2:LEHIGH ACRES
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33976
Practice Address - Country:US
Practice Address - Phone:239-368-2100
Practice Address - Fax:239-368-2289
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38635183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist