Provider Demographics
NPI:1114922796
Name:SHETH, SAURABH H (RPH)
Entity Type:Individual
Prefix:MR
First Name:SAURABH
Middle Name:H
Last Name:SHETH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:SAM
Other - Middle Name:H
Other - Last Name:SHETH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:42 KEMI LN
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-1150
Mailing Address - Country:US
Mailing Address - Phone:631-732-3268
Mailing Address - Fax:
Practice Address - Street 1:111-BEDFORD AVE
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710
Practice Address - Country:US
Practice Address - Phone:516-221-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044206183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02498199Medicaid
NY509413001Medicare PIN