Provider Demographics
NPI:1619299070
Name:SHAH, JAYESH K (RPH)
Entity Type:Individual
Prefix:MR
First Name:JAYESH
Middle Name:K
Last Name:SHAH
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 1:99-1 RTE 25A
Mailing Address - Street 2:PO BOX 876
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786
Mailing Address - Country:US
Mailing Address - Phone:631-821-0707
Mailing Address - Fax:
Practice Address - Street 1:99-1 RTE 25A
Practice Address - Street 2:
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786
Practice Address - Country:US
Practice Address - Phone:631-821-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist