MEDICARE: BALAKA SAMPATHKUMAR

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	PS60213	FL

General Provider Information

NPI Number	:	1861005621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BALAKA SAMPATHKUMAR

Provider Business Mailing Address
First Line	:	5475 MURRELL RD
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-6665
Country	:	US
Telephone Number	:	321-631-3732
Fax Number	:

Provider Business Practice Location Address
First Line	:	5475 MURRELL RD
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32955-6665
Country	:	US
Telephone Number	:	321-631-3732
Fax Number	:

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

Provider Enumeration Date	:	08/30/2020
Last Update Date	:	08/30/2020

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Directions to “ BALAKA SAMPATHKUMAR ” Practice Location

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