Provider Demographics
NPI:1093317992
Name:GANDHI, PRATIK
Entity Type:Individual
Prefix:
First Name:PRATIK
Middle Name:
Last Name:GANDHI
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 1:160 HIAWATHA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE HIAWATHA
Mailing Address - State:NJ
Mailing Address - Zip Code:07034-2213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 HIAWATHA BLVD
Practice Address - Street 2:
Practice Address - City:LAKE HIAWATHA
Practice Address - State:NJ
Practice Address - Zip Code:07034-2213
Practice Address - Country:US
Practice Address - Phone:862-222-6514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-15
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03801900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist