Provider Demographics
NPI:1952693558
Name:KOTHA, SUREKHA
Entity Type:Individual
Prefix:
First Name:SUREKHA
Middle Name:
Last Name:KOTHA
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 1:275 ARELLA WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-1252
Mailing Address - Country:US
Mailing Address - Phone:048-067-8149
Mailing Address - Fax:
Practice Address - Street 1:2680 RACE TRACK RD
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-6278
Practice Address - Country:US
Practice Address - Phone:904-230-6718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-14
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57398183500000X
PARP444286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist