Provider Demographics
NPI:1912292244
Name:TINUMALA PHARMACY P C
Entity type:Organization
Organization Name:TINUMALA PHARMACY P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NAGESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKHAMOORI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-343-4434
Mailing Address - Street 1:4543 PLEASANT HILL RD
Mailing Address - Street 2:STE D & E
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-3403
Mailing Address - Country:US
Mailing Address - Phone:407-343-4434
Mailing Address - Fax:407-574-8790
Practice Address - Street 1:4543 PLEASANT HILL RD
Practice Address - Street 2:STE D & E
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759-3403
Practice Address - Country:US
Practice Address - Phone:407-343-4434
Practice Address - Fax:407-574-8790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH255183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153452OtherPK
FL003867000Medicaid