Provider Demographics
NPI:1376954834
Name:SHAH, HETAL
Entity Type:Individual
Prefix:
First Name:HETAL
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 E BIDWELL ST
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3341
Mailing Address - Country:US
Mailing Address - Phone:916-983-6574
Mailing Address - Fax:916-983-2639
Practice Address - Street 1:715 E BIDWELL ST
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3341
Practice Address - Country:US
Practice Address - Phone:916-983-6574
Practice Address - Fax:916-983-2639
Is Sole Proprietor?:No
Enumeration Date:2014-05-17
Last Update Date:2014-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59387183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist