Healthcare Provider Details

I. General information

NPI: 1699440644
Provider Name (Legal Business Name): SRILATHA ANUMASU RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 BLACKFORD WAY
SAINT AUGUSTINE FL
32086-1876
US

IV. Provider business mailing address

824 CHANTERELLE WAY
SAINT JOHNS FL
32259-8000
US

V. Phone/Fax

Practice location:
  • Phone: 904-436-0006
  • Fax:
Mailing address:
  • Phone: 732-567-2138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS38551
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: