Provider Demographics
NPI:1457503054
Name:SHAH, DIPAK J
Entity Type:Individual
Prefix:MR
First Name:DIPAK
Middle Name:J
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 1:295 CENTRAL AVENUE
Mailing Address - Street 2:SACHIN PHARMACY INC.
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307
Mailing Address - Country:US
Mailing Address - Phone:201-653-1200
Mailing Address - Fax:201-653-1205
Practice Address - Street 1:295 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307
Practice Address - Country:US
Practice Address - Phone:201-653-1200
Practice Address - Fax:201-653-1205
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRI02008800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7822502Medicaid
NJ7822502Medicaid