Provider Demographics
NPI:1255653929
Name:THAKER, SHRUTI D (RPH)
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:D
Last Name:THAKER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 SUFFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4409
Mailing Address - Country:US
Mailing Address - Phone:631-273-3314
Mailing Address - Fax:631-273-8863
Practice Address - Street 1:761 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4409
Practice Address - Country:US
Practice Address - Phone:631-273-3314
Practice Address - Fax:631-273-8863
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048097183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist