Provider Demographics
NPI:1841708518
Name:SHAH, PRATIK R
Entity type:Individual
Prefix:
First Name:PRATIK
Middle Name:R
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 1:5210 BAGBY AVE APT NO121
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76711-2308
Mailing Address - Country:US
Mailing Address - Phone:832-420-4361
Mailing Address - Fax:
Practice Address - Street 1:5210 BAGBY AVE APT 121
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-2309
Practice Address - Country:US
Practice Address - Phone:832-420-4361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27212183500000X
TX59225183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist