Provider Demographics
NPI:1215228705
Name:SHAH, SHREYAS SURESH (RPH)
Entity Type:Individual
Prefix:MR
First Name:SHREYAS
Middle Name:SURESH
Last Name:SHAH
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 1:48 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-2125
Mailing Address - Country:US
Mailing Address - Phone:201-567-2235
Mailing Address - Fax:201-567-1881
Practice Address - Street 1:48 UNION AVE
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626-2125
Practice Address - Country:US
Practice Address - Phone:201-567-2235
Practice Address - Fax:201-567-1881
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02351800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0145611Medicaid
NJ0145611Medicaid