MEDICARE: TIRUMALA PHARMACY INC

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	3336C0004X	Compounding Pharmacy
2	3336S0011X	Specialty Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PH25563	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5706582	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1275821134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIRUMALA PHARMACY INC

Provider Business Mailing Address
First Line	:	4106 W LAKE MARY BLVD
Second Line	:	#130
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3315
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	:	DIRECTOR/PHARMACY MANAGER
Name	:	MR. SIVARAMAKRISHNA KONDAPALLI
Credential	:
Telephone Number	:	407-878-7615

Provider Enumeration Date	:	07/13/2011
Last Update Date	:	10/30/2015

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Directions to “TIRUMALA PHARMACY INC ” Practice Location

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