Provider Demographics
NPI:1629672977
Name:SHAH, MANISH YOGENDRA
Entity Type:Individual
Prefix:
First Name:MANISH
Middle Name:YOGENDRA
Last Name:SHAH
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 1:407 SUNCHASE BLVD APT K
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-2898
Mailing Address - Country:US
Mailing Address - Phone:848-482-0304
Mailing Address - Fax:
Practice Address - Street 1:1800 PEERY DR
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2377
Practice Address - Country:US
Practice Address - Phone:434-392-1639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202209593183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist