Provider Demographics
NPI:1376146498
Name:SHAH, PALLAV
Entity Type:Individual
Prefix:
First Name:PALLAV
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 1:824 N BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:RUNNEMEDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08078-1034
Mailing Address - Country:US
Mailing Address - Phone:856-939-5656
Mailing Address - Fax:
Practice Address - Street 1:824 N BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:RUNNEMEDE
Practice Address - State:NJ
Practice Address - Zip Code:08078-1034
Practice Address - Country:US
Practice Address - Phone:856-939-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
NJ28RI03824000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy