Provider Demographics
NPI:1053659425
Name:PATEL, PRASHANT K (MS, MBA, R PH)
Entity Type:Individual
Prefix:MR
First Name:PRASHANT
Middle Name:K
Last Name:PATEL
Suffix:
Gender:M
Credentials:MS, MBA, R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MOODY BLVD
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136-3372
Mailing Address - Country:US
Mailing Address - Phone:904-728-7283
Mailing Address - Fax:386-426-6600
Practice Address - Street 1:200 MOODY BLVD
Practice Address - Street 2:
Practice Address - City:FLAGLER BEACH
Practice Address - State:FL
Practice Address - Zip Code:32136-6127
Practice Address - Country:US
Practice Address - Phone:904-728-7283
Practice Address - Fax:386-426-6600
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-19
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS36305183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106538600Medicaid