Provider Demographics
NPI:1083395206
Name:PATEL, SHIVAM HITESHKUMAR
Entity Type:Individual
Prefix:
First Name:SHIVAM
Middle Name:HITESHKUMAR
Last Name:PATEL
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 1:4464 HIGHWAY 198
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:GA
Mailing Address - Zip Code:30547-1804
Mailing Address - Country:US
Mailing Address - Phone:706-499-4484
Mailing Address - Fax:
Practice Address - Street 1:1625 PLEASANT HILL RD STE 200
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5863
Practice Address - Country:US
Practice Address - Phone:770-806-2787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH034402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist