Provider Demographics
NPI:1174680235
Name:SHUKLA, KAUSTUBH G (R PH)
Entity Type:Individual
Prefix:MR
First Name:KAUSTUBH
Middle Name:G
Last Name:SHUKLA
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:KAUSTUBH
Other - Middle Name:G
Other - Last Name:SHUKLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3 SANDRA DR
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:603 W 4TH ST
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-2006
Practice Address - Country:US
Practice Address - Phone:908-756-2599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02189100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist