Provider Demographics
NPI:1528664620
Name:PINNAMANENI, SUDHAKAR
Entity type:Individual
Prefix:
First Name:SUDHAKAR
Middle Name:
Last Name:PINNAMANENI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4901
Mailing Address - Country:US
Mailing Address - Phone:863-676-2564
Mailing Address - Fax:
Practice Address - Street 1:500 S 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4901
Practice Address - Country:US
Practice Address - Phone:863-676-2564
Practice Address - Fax:863-678-1353
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS42059183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist