Provider Demographics
NPI:1619353422
Name:TRIVEDI, PRALOK
Entity Type:Individual
Prefix:
First Name:PRALOK
Middle Name:
Last Name:TRIVEDI
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 1:5575 W AMELIA EARHART DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3715
Mailing Address - Country:US
Mailing Address - Phone:707-218-1189
Mailing Address - Fax:
Practice Address - Street 1:31 FAIRMOUNT AVE
Practice Address - Street 2:APARTMENT: BASEMENT
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-5955
Practice Address - Country:US
Practice Address - Phone:707-218-1189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist