Provider Demographics
NPI:1679747349
Name:SHAH, SANJAYKUMAR KANTILAL (RPH)
Entity Type:Individual
Prefix:MR
First Name:SANJAYKUMAR
Middle Name:KANTILAL
Last Name:SHAH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 STATE ROAD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4329
Mailing Address - Country:US
Mailing Address - Phone:863-676-9496
Mailing Address - Fax:863-678-1829
Practice Address - Street 1:1903 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4329
Practice Address - Country:US
Practice Address - Phone:863-676-9496
Practice Address - Fax:863-678-1829
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 43160183500000X
TX45819183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist