Provider Demographics
NPI:1710566377
Name:PATEL, SUKETU
Entity Type:Individual
Prefix:
First Name:SUKETU
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 1:11509 DR. MLK JR. BLVD
Mailing Address - Street 2:
Mailing Address - City:MANGO
Mailing Address - State:FL
Mailing Address - Zip Code:33550
Mailing Address - Country:US
Mailing Address - Phone:813-661-2263
Mailing Address - Fax:813-662-2263
Practice Address - Street 1:11509 DR. MLK JR. BLVD
Practice Address - Street 2:
Practice Address - City:MANGO
Practice Address - State:FL
Practice Address - Zip Code:33550
Practice Address - Country:US
Practice Address - Phone:813-661-2263
Practice Address - Fax:813-662-2263
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist