Provider Demographics
NPI:1740785807
Name:PATEL, HETALKUMAR (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:HETALKUMAR
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 VICTORIA AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-7022
Mailing Address - Country:US
Mailing Address - Phone:917-698-4933
Mailing Address - Fax:
Practice Address - Street 1:5TH AVENUE AND ROOSEVELT ROAD
Practice Address - Street 2:BLDG 37 NW
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141
Practice Address - Country:US
Practice Address - Phone:770-554-3545
Practice Address - Fax:708-786-4490
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051294793183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist