Provider Demographics
NPI:1821555442
Name:DESAI, DIPAL SURENDRA
Entity Type:Individual
Prefix:MR
First Name:DIPAL
Middle Name:SURENDRA
Last Name:DESAI
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 1:11720 E DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-4923
Mailing Address - Country:US
Mailing Address - Phone:813-684-0292
Mailing Address - Fax:813-653-2632
Practice Address - Street 1:11720 DR MARTIN LUTHER KING BOULEVARD
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584
Practice Address - Country:US
Practice Address - Phone:813-684-0292
Practice Address - Fax:813-653-2632
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist