Provider Demographics
NPI:1518197607
Name:DESAI, VISHAL V
Entity Type:Individual
Prefix:
First Name:VISHAL
Middle Name:V
Last Name:DESAI
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:PO BOX 6781
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-6781
Mailing Address - Country:US
Mailing Address - Phone:631-965-5108
Mailing Address - Fax:
Practice Address - Street 1:15025, OLYMPIC DRIVE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422
Practice Address - Country:US
Practice Address - Phone:707-994-8677
Practice Address - Fax:707-994-5003
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAINT22944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist