Provider Demographics
NPI:1114565785
Name:PATEL, PRANAV K
Entity Type:Individual
Prefix:
First Name:PRANAV
Middle Name:K
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 1:2000 STATE ROAD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33898-5182
Mailing Address - Country:US
Mailing Address - Phone:863-676-9468
Mailing Address - Fax:863-678-3715
Practice Address - Street 1:2000 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33898-5182
Practice Address - Country:US
Practice Address - Phone:863-676-9468
Practice Address - Fax:863-678-3715
Is Sole Proprietor?:No
Enumeration Date:2019-12-14
Last Update Date:2019-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS43701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist