Provider Demographics
NPI:1578734562
Name:SHAH, SUDHIR R
Entity Type:Individual
Prefix:MR
First Name:SUDHIR
Middle Name:R
Last Name:SHAH
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 1:17 AGATHA DR
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2251
Mailing Address - Country:US
Mailing Address - Phone:732-287-3969
Mailing Address - Fax:
Practice Address - Street 1:2730 ARTHUR KILL RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-1135
Practice Address - Country:US
Practice Address - Phone:718-984-8172
Practice Address - Fax:718-984-9434
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036299-1183500000X
NJRI 01901400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY036299-1OtherNY STATE BOARD OF PHARMAC
NJRI 01901400OtherNJ BOARD OF PHARMACY