Provider Demographics
NPI:1912433095
Name:VENUGOPAL, SHANTHA DEVI (RPH)
Entity Type:Individual
Prefix:
First Name:SHANTHA
Middle Name:DEVI
Last Name:VENUGOPAL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3787 WINKLER AVE
Mailing Address - Street 2:EXT 328
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-7760
Mailing Address - Country:US
Mailing Address - Phone:845-702-4866
Mailing Address - Fax:
Practice Address - Street 1:2692 OAK RIDGE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9351
Practice Address - Country:US
Practice Address - Phone:239-939-9226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 55743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist