Provider Demographics
NPI:1649671108
Name:PATEL, NISHA
Entity type:Individual
Prefix:
First Name:NISHA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12201 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2573
Mailing Address - Country:US
Mailing Address - Phone:909-646-9366
Mailing Address - Fax:909-646-9375
Practice Address - Street 1:12201 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-2573
Practice Address - Country:US
Practice Address - Phone:909-646-9366
Practice Address - Fax:909-646-9375
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS020858183500000X
NV18792183500000X
CA763201835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist