Provider Demographics
NPI:1407137102
Name:SHAH, KETAN H (BS RPH)
Entity Type:Individual
Prefix:MR
First Name:KETAN
Middle Name:H
Last Name:SHAH
Suffix:
Gender:M
Credentials:BS RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 WOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3504
Mailing Address - Country:US
Mailing Address - Phone:732-318-3046
Mailing Address - Fax:732-379-5760
Practice Address - Street 1:153 WOOD AVE
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3504
Practice Address - Country:US
Practice Address - Phone:732-318-3046
Practice Address - Fax:732-379-5760
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02170800183500000X
FLPS27026183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist