Provider Demographics
NPI:1407459696
Name:PATEL, PRAHLAD
Entity Type:Individual
Prefix:
First Name:PRAHLAD
Middle Name:
Last Name:PATEL
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 1:414 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-4022
Mailing Address - Country:US
Mailing Address - Phone:904-241-2461
Mailing Address - Fax:904-246-6276
Practice Address - Street 1:414 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-4022
Practice Address - Country:US
Practice Address - Phone:904-241-2461
Practice Address - Fax:904-246-6276
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS314323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy