Provider Demographics
NPI:1245834522
Name:SHAH, HARDIK
Entity type:Individual
Prefix:
First Name:HARDIK
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 1:100 SW WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-4712
Mailing Address - Country:US
Mailing Address - Phone:817-295-1125
Mailing Address - Fax:
Practice Address - Street 1:100 SW WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4712
Practice Address - Country:US
Practice Address - Phone:817-295-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55983183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist