Provider Demographics
NPI:1033366588
Name:SHAH, DIPESH K
Entity Type:Individual
Prefix:
First Name:DIPESH
Middle Name:K
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8637 RANGE ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2721
Mailing Address - Country:US
Mailing Address - Phone:718-776-9845
Mailing Address - Fax:
Practice Address - Street 1:86-37 RANGE ST.
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-3001
Practice Address - Country:US
Practice Address - Phone:718-766-9845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052355183500000X
NJ28RI03172900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist