Provider Demographics
NPI:1184859902
Name:LAGDIWALA, DIMPLE PIYUSHKUMAR I (SUPERVISING PHAR)
Entity Type:Individual
Prefix:MR
First Name:DIMPLE
Middle Name:PIYUSHKUMAR
Last Name:LAGDIWALA
Suffix:I
Gender:M
Credentials:SUPERVISING PHAR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 EVENTIDE CT
Mailing Address - Street 2:
Mailing Address - City:MORRIS PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07950-1155
Mailing Address - Country:US
Mailing Address - Phone:973-640-3916
Mailing Address - Fax:718-466-1076
Practice Address - Street 1:115A FEATHERBED LN
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-1615
Practice Address - Country:US
Practice Address - Phone:718-466-1790
Practice Address - Fax:718-466-1076
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY047293OtherNYWTORK LICENCE