MEDICARE: SREENIVASA KRISHNASWAMY RPH

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	PS39511	FL

General Provider Information

NPI Number	:	1215524509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SREENIVASA KRISHNASWAMY RPH

Provider Business Mailing Address
First Line	:	6846 VINTAGE LN
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-4093
Country	:	US
Telephone Number	:
Fax Number	:

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	:	407-878-7615

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

Provider Enumeration Date	:	12/21/2020
Last Update Date	:	12/21/2020

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