Provider Demographics
NPI:1265055107
Name:PATEL, PRIYANK
Entity type:Individual
Prefix:
First Name:PRIYANK
Middle Name:
Last Name:PATEL
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 1:1201 WOODHAVEN BLVD STE 1221
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-2377
Mailing Address - Country:US
Mailing Address - Phone:817-653-7454
Mailing Address - Fax:
Practice Address - Street 1:5317 SUMMER MEADOWS DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-1975
Practice Address - Country:US
Practice Address - Phone:682-429-5259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist