Provider Demographics
NPI:1093092520
Name:SHAH, MAMTA
Entity Type:Individual
Prefix:
First Name:MAMTA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12471 LIMONITE AVE
Mailing Address - Street 2:T1961
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-2457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12471 LIMONITE AVE
Practice Address - Street 2:T1961
Practice Address - City:MIRA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91752-2457
Practice Address - Country:US
Practice Address - Phone:951-256-5262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57777183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist