Provider Demographics
NPI:1619151156
Name:SHAH, KIRTIDA PANKAJ
Entity Type:Individual
Prefix:
First Name:KIRTIDA
Middle Name:PANKAJ
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 37TH AVE
Mailing Address - Street 2:DUANE READE
Mailing Address - City:JACKSON HEIGHT
Mailing Address - State:NY
Mailing Address - Zip Code:11372
Mailing Address - Country:US
Mailing Address - Phone:718-672-8038
Mailing Address - Fax:718-478-7928
Practice Address - Street 1:7301 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6326
Practice Address - Country:US
Practice Address - Phone:718-672-8038
Practice Address - Fax:718-478-7928
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044220-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist