Healthcare Provider Details

I. General information

NPI: 1932806817
Provider Name (Legal Business Name): ADITYA MANI PERUMAL PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 ARAPAHO AVE
SAINT AUGUSTINE FL
32084-4203
US

IV. Provider business mailing address

140 HISTORIC BRICK LN
ST AUGUSTINE FL
32095-8020
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-9919
  • Fax: 904-829-2617
Mailing address:
  • Phone: 904-386-5975
  • Fax: 904-829-2617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPSI37987
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: