Provider Demographics
NPI:1790934461
Name:VAIDYA, IMESH C (RPH)
Entity Type:Individual
Prefix:MR
First Name:IMESH
Middle Name:C
Last Name:VAIDYA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10236 COORS BYP NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4088
Mailing Address - Country:US
Mailing Address - Phone:505-898-1730
Mailing Address - Fax:505-890-8035
Practice Address - Street 1:10236 COORS BYP NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4088
Practice Address - Country:US
Practice Address - Phone:505-898-1730
Practice Address - Fax:505-890-8035
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP5910183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist