Provider Demographics
NPI:1063071793
Name:JAGTAP, NEELAM
Entity type:Individual
Prefix:
First Name:NEELAM
Middle Name:
Last Name:JAGTAP
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 1:15840 HESPERIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:CA
Mailing Address - Zip Code:94580-1538
Mailing Address - Country:US
Mailing Address - Phone:510-276-9395
Mailing Address - Fax:
Practice Address - Street 1:15840 HESPERIAN BLVD
Practice Address - Street 2:
Practice Address - City:SAN LORENZO
Practice Address - State:CA
Practice Address - Zip Code:94580-1538
Practice Address - Country:US
Practice Address - Phone:510-276-9395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA60712183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist