Provider Demographics
NPI:1689031650
Name:BHAGAT, JIGNESH
Entity Type:Individual
Prefix:
First Name:JIGNESH
Middle Name:
Last Name:BHAGAT
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 1:50209 BLACK HORSE LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2287
Mailing Address - Country:US
Mailing Address - Phone:734-858-7088
Mailing Address - Fax:
Practice Address - Street 1:9131 GENERAL CT
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4621
Practice Address - Country:US
Practice Address - Phone:734-416-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2016-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036623183500000X
FLPS39508183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist