Provider Demographics
NPI:1912453051
Name:SHAH, HETAL
Entity Type:Individual
Prefix:
First Name:HETAL
Middle Name:
Last Name:SHAH
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 1:21398 PRICE CASCADES PLZ
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-6606
Mailing Address - Country:US
Mailing Address - Phone:703-406-7048
Mailing Address - Fax:
Practice Address - Street 1:21398 PRICE CASCADES PLZ
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-6606
Practice Address - Country:US
Practice Address - Phone:703-406-7048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202207738183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist