Provider Demographics
NPI:1194002469
Name:PERTAB, SHIV R (RPH)
Entity Type:Individual
Prefix:MR
First Name:SHIV
Middle Name:R
Last Name:PERTAB
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:CHEVY
Other - Middle Name:R
Other - Last Name:PERTAB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:1230 MARKET ST # 324
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-4801
Mailing Address - Country:US
Mailing Address - Phone:510-848-5121
Mailing Address - Fax:510-545-5350
Practice Address - Street 1:2310 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1613
Practice Address - Country:US
Practice Address - Phone:510-848-5121
Practice Address - Fax:510-848-5350
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH56386183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist