Provider Demographics
NPI:1255330338
Name:PATEL, KETAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KETAN
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12648 BOUGAINVILLEA WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-7024
Mailing Address - Country:US
Mailing Address - Phone:909-648-4533
Mailing Address - Fax:
Practice Address - Street 1:12648 BOUGAINVILLEA WAY
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-7024
Practice Address - Country:US
Practice Address - Phone:909-648-4533
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH52341183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPH52341OtherPHARMACIST