Provider Demographics
NPI:1518249465
Name:TRIVEDI, VISHAL
Entity Type:Individual
Prefix:
First Name:VISHAL
Middle Name:
Last Name:TRIVEDI
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 1:3464 COLONIAL AVE
Mailing Address - Street 2:APARTMENT# B-10
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-4567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2707 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-9104
Practice Address - Country:US
Practice Address - Phone:276-632-0180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202209167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist