Provider Demographics
NPI:1669912846
Name:SHAH, KAMLESH RASIKLAL
Entity type:Individual
Prefix:
First Name:KAMLESH
Middle Name:RASIKLAL
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 1:6851 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5294
Mailing Address - Country:US
Mailing Address - Phone:630-452-1841
Mailing Address - Fax:773-874-0464
Practice Address - Street 1:8419 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6113
Practice Address - Country:US
Practice Address - Phone:773-874-0425
Practice Address - Fax:773-874-0464
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051032678183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist