Provider Demographics
NPI:1760867550
Name:SHAH, GINA (PHARMD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 BROOKVIEW CT
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-5544
Mailing Address - Country:US
Mailing Address - Phone:860-912-6907
Mailing Address - Fax:
Practice Address - Street 1:90 QUAKER LN
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-0111
Practice Address - Country:US
Practice Address - Phone:401-821-2623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0013318183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist