Provider Demographics
NPI:1063728400
Name:MEHTA, JAY M
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:M
Last Name:MEHTA
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 1:5059 MILLAY CT
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-3869
Mailing Address - Country:US
Mailing Address - Phone:760-941-0712
Mailing Address - Fax:760-941-5334
Practice Address - Street 1:3813 PLAZA DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4624
Practice Address - Country:US
Practice Address - Phone:760-941-0712
Practice Address - Fax:760-941-5334
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48115183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist