Provider Demographics
NPI:1578163432
Name:SHRIVASTAVA, PANKAJ K (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:PANKAJ
Middle Name:K
Last Name:SHRIVASTAVA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8B MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-7974
Mailing Address - Country:US
Mailing Address - Phone:410-553-4156
Mailing Address - Fax:410-595-6960
Practice Address - Street 1:8B MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-7974
Practice Address - Country:US
Practice Address - Phone:410-553-4156
Practice Address - Fax:410-595-6960
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23793183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist