MEDICARE: BALA KODE PHARMD

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	PS35148	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS35148	OTHER	FL	BOARD OF PHARMACY

General Provider Information

NPI Number	:	1710590815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BALA KODE PHARMD

Provider Business Mailing Address
First Line	:	2306 NORTH BLVD W STE A
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-8976
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2306 NORTH BLVD W STE A
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33837-8976
Country	:	US
Telephone Number	:	863-547-9922
Fax Number	:

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

Provider Enumeration Date	:	08/28/2020
Last Update Date	:	08/28/2020

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Directions to “ BALA KODE PHARMD” Practice Location

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