Provider Demographics
NPI:1619577269
Name:PATEL, SUBHASH
Entity Type:Individual
Prefix:
First Name:SUBHASH
Middle Name:
Last Name:PATEL
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 1:2575 LUPINE DR
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5110 TIMES SQUARE PL
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1161
Practice Address - Country:US
Practice Address - Phone:217-871-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist