Provider Demographics
NPI:1801227707
Name:SHAH, VIKRAM (RPH)
Entity Type:Individual
Prefix:
First Name:VIKRAM
Middle Name:
Last Name:SHAH
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 1:801 W LAKE STREET
Mailing Address - Street 2:KROGER PHARMACY
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-682-2983
Mailing Address - Fax:309-682-3128
Practice Address - Street 1:801 W LAKE STREET
Practice Address - Street 2:KROGER PHARMACY
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-682-2983
Practice Address - Fax:309-682-3128
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-032995183500000X
CA35369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist