Provider Demographics
NPI:1750054268
Name:PATEL, KAUSHIK BANSILAL
Entity Type:Individual
Prefix:
First Name:KAUSHIK
Middle Name:BANSILAL
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 1:2764 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-3517
Mailing Address - Country:US
Mailing Address - Phone:818-248-5851
Mailing Address - Fax:818-248-6292
Practice Address - Street 1:2764 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-3517
Practice Address - Country:US
Practice Address - Phone:818-248-5851
Practice Address - Fax:818-248-6292
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH43824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist