Provider Demographics
NPI:1619244290
Name:DESAI, TEJAS RAMESH (RPH)
Entity Type:Individual
Prefix:MR
First Name:TEJAS
Middle Name:RAMESH
Last Name:DESAI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25401 75TH ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:53168-9527
Mailing Address - Country:US
Mailing Address - Phone:262-843-1550
Mailing Address - Fax:
Practice Address - Street 1:25401 75TH ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:WI
Practice Address - Zip Code:53168-9527
Practice Address - Country:US
Practice Address - Phone:262-843-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-25
Last Update Date:2011-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292884183500000X
WI14194-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051.292884OtherLICENSE NUMBER
WI14194-040OtherLICENSE NUMBER