Provider Demographics
NPI:1134126808
Name:GHAYAL, KAUSHIK (RPH)
Entity Type:Individual
Prefix:MR
First Name:KAUSHIK
Middle Name:
Last Name:GHAYAL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7135 N US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOHN
Mailing Address - State:FL
Mailing Address - Zip Code:32927-5087
Mailing Address - Country:US
Mailing Address - Phone:321-631-0300
Mailing Address - Fax:321-631-2728
Practice Address - Street 1:7135 N US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST JOHN
Practice Address - State:FL
Practice Address - Zip Code:32927-5087
Practice Address - Country:US
Practice Address - Phone:321-631-0300
Practice Address - Fax:321-631-2728
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22412183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100581500Medicaid