Provider Demographics
NPI:1225328420
Name:PATEL, INDRA ANDY (RPH)
Entity Type:Individual
Prefix:MR
First Name:INDRA
Middle Name:ANDY
Last Name:PATEL
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 1:525 KENION FOREST WAY
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-8817
Mailing Address - Country:US
Mailing Address - Phone:404-488-6799
Mailing Address - Fax:
Practice Address - Street 1:2979 FIVE FORKS TRICKUM RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5873
Practice Address - Country:US
Practice Address - Phone:770-979-8121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-10
Last Update Date:2011-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH011216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist