Provider Demographics
NPI:1760869747
Name:SHAH, SAMIR
Entity Type:Individual
Prefix:MR
First Name:SAMIR
Middle Name:
Last Name:SHAH
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 1:638 BAYWAY AVENUE
Mailing Address - Street 2:GOETHALS PHARMACY
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202
Mailing Address - Country:US
Mailing Address - Phone:908-527-1112
Mailing Address - Fax:908-527-1155
Practice Address - Street 1:2675 KENNEDY BLVD
Practice Address - Street 2:APT K
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-5847
Practice Address - Country:US
Practice Address - Phone:201-682-6204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03691300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist