Provider Demographics
NPI:1356489165
Name:SHAH, CHETAN
Entity Type:Individual
Prefix:
First Name:CHETAN
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MACKAY WAY
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-2175
Mailing Address - Country:US
Mailing Address - Phone:516-484-7399
Mailing Address - Fax:
Practice Address - Street 1:410 LAKEVILLE RD STE 102
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1102
Practice Address - Country:US
Practice Address - Phone:516-352-2337
Practice Address - Fax:516-775-0595
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039243183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist