Provider Demographics
NPI:1558680736
Name:SHETTY, PREMNATH V
Entity Type:Individual
Prefix:
First Name:PREMNATH
Middle Name:V
Last Name:SHETTY
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 1:1180 RUSTLING WIND LN
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-3052
Mailing Address - Country:US
Mailing Address - Phone:972-375-7862
Mailing Address - Fax:
Practice Address - Street 1:308 SEAWALL BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550-5522
Practice Address - Country:US
Practice Address - Phone:409-763-3588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist