Provider Demographics
NPI:1023575990
Name:SHAH, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
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 1:164 SAINT PAULS AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-2610
Mailing Address - Country:US
Mailing Address - Phone:201-618-0821
Mailing Address - Fax:
Practice Address - Street 1:205 VINEYARD RD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-4785
Practice Address - Country:US
Practice Address - Phone:732-491-2023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03513500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist