Provider Demographics
NPI:1063504850
Name:SHAH, SANJAY K (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:SANJAY
Middle Name:K
Last Name:SHAH
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:MR
Other - First Name:SANJAY
Other - Middle Name:K
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:200 CHESTNUT ST
Mailing Address - Street 2:P O BOX 167
Mailing Address - City:ROSELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07204-2263
Mailing Address - Country:US
Mailing Address - Phone:908-245-1396
Mailing Address - Fax:908-245-1616
Practice Address - Street 1:200 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ROSELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07204-2263
Practice Address - Country:US
Practice Address - Phone:908-245-1396
Practice Address - Fax:908-245-1616
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02232500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0102831Medicaid
5690190001Medicare NSC