Provider Demographics
NPI:1215524509
Name:KRISHNASWAMY, SREENIVASA (RPH)
Entity type:Individual
Prefix:
First Name:SREENIVASA
Middle Name:
Last Name:KRISHNASWAMY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:SREENIVASA
Other - Middle Name:
Other - Last Name:KRISHNASWAMY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:6846 VINTAGE LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-4093
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4106 W LAKE MARY BLVD STE 130
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3383
Practice Address - Country:US
Practice Address - Phone:407-878-7615
Practice Address - Fax:407-878-7615
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39511183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist