Provider Demographics
NPI:1477852069
Name:MODI, ASHESH
Entity Type:Individual
Prefix:
First Name:ASHESH
Middle Name:
Last Name:MODI
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 1:6165 EASTKNOLL DR
Mailing Address - Street 2:APT#497
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6165 EASTKNOLL DR
Practice Address - Street 2:APT#497
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-5032
Practice Address - Country:US
Practice Address - Phone:201-993-1996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035494183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist