Provider Demographics
NPI:1619373586
Name:TAKTAWALA, JAIMIN
Entity Type:Individual
Prefix:
First Name:JAIMIN
Middle Name:
Last Name:TAKTAWALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAIMIN
Other - Middle Name:
Other - Last Name:TAKTAWALA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:20125 OAKFLOWER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3649
Mailing Address - Country:US
Mailing Address - Phone:813-884-4884
Mailing Address - Fax:813-886-1690
Practice Address - Street 1:7095 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-2291
Practice Address - Country:US
Practice Address - Phone:813-884-4884
Practice Address - Fax:813-886-1690
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44533183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist