MEDICARE: SIVA RAMA KRISHNA KONDAPALLI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS40111	FL

General Provider Information

NPI Number	:	1194298901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIVA RAMA KRISHNA KONDAPALLI

Provider Business Mailing Address
First Line	:	4106 W LAKE MARY BLVD STE 130
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3383
Country	:	US
Telephone Number	:	407-878-7615
Fax Number	:	407-878-7616

Provider Business Practice Location Address
First Line	:	4106 W LAKE MARY BLVD STE 130
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3383
Country	:	US
Telephone Number	:	407-878-7615
Fax Number	:	407-878-7616

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2019
Last Update Date	:	01/03/2019

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