Provider Demographics
NPI:1669819140
Name:SHAH, KRUTIKA
Entity Type:Individual
Prefix:
First Name:KRUTIKA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 E FOOTHILL BLVD
Mailing Address - Street 2:101
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4027
Mailing Address - Country:US
Mailing Address - Phone:909-982-1778
Mailing Address - Fax:909-981-9418
Practice Address - Street 1:1060 E FOOTHILL BLVD
Practice Address - Street 2:101
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4027
Practice Address - Country:US
Practice Address - Phone:909-982-1778
Practice Address - Fax:909-981-9418
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH451661835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist