MEDICARE: SHERIN ITTIAVIRAH

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	PS47283	FL

General Provider Information

NPI Number	:	1437428711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERIN ITTIAVIRAH

Provider Business Mailing Address
First Line	:	2315 BLACK LAKE BLVD
Second Line	:
City	:	WINTER GARDEN
State	:	FL
Zip	:	34787-4756
Country	:	US
Telephone Number	:	407-656-4547
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 W STATE ROAD 436
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-2736
Country	:	US
Telephone Number	:	407-389-7353
Fax Number	:

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

Provider Enumeration Date	:	12/15/2011
Last Update Date	:	12/15/2011

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Directions to “ SHERIN ITTIAVIRAH ” Practice Location

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