Provider Demographics
NPI:1538690169
Name:PATEL, PRADEEPKUMAR R
Entity Type:Individual
Prefix:MR
First Name:PRADEEPKUMAR
Middle Name:R
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 1:5414 BROOK HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2440
Mailing Address - Country:US
Mailing Address - Phone:209-810-2619
Mailing Address - Fax:
Practice Address - Street 1:300-G PULLMAN STREET
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551
Practice Address - Country:US
Practice Address - Phone:925-294-9667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42297183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist