Provider Demographics
NPI:1104310812
Name:SHAH, GIRISH R
Entity type:Individual
Prefix:MR
First Name:GIRISH
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 1:12721 MORENO BEACH DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4411
Mailing Address - Country:US
Mailing Address - Phone:951-242-6599
Mailing Address - Fax:951-242-5991
Practice Address - Street 1:12721 MORENO BEACH DR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4411
Practice Address - Country:US
Practice Address - Phone:951-242-6599
Practice Address - Fax:951-242-5991
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43657333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy