Provider Demographics
NPI:1225746134
Name:PATEL, MANISH R (MP)
Entity Type:Individual
Prefix:
First Name:MANISH
Middle Name:R
Last Name:PATEL
Suffix:
Gender:M
Credentials:MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10448 CRESTON GLEN CIR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-4695
Mailing Address - Country:US
Mailing Address - Phone:904-707-9460
Mailing Address - Fax:
Practice Address - Street 1:152 FRONT ST
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-3058
Practice Address - Country:US
Practice Address - Phone:904-285-3634
Practice Address - Fax:904-285-7374
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39482183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist