Provider Demographics
NPI:1679857536
Name:PATEL, MANISH
Entity Type:Individual
Prefix:MR
First Name:MANISH
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 1:1700 W HICKORY GROVE RD
Mailing Address - Street 2:APT 3-209
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-9592
Mailing Address - Country:US
Mailing Address - Phone:847-858-4901
Mailing Address - Fax:
Practice Address - Street 1:1700 W. HICKORY GROVE RD
Practice Address - Street 2:APT 3-209
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525
Practice Address - Country:US
Practice Address - Phone:847-858-4901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.294671183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist