Provider Demographics
NPI:1124675012
Name:SHAH, KEYA
Entity type:Individual
Prefix:
First Name:KEYA
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 1:5358 BELLAGGIO CRESCENT
Mailing Address - Street 2:
Mailing Address - City:MISSISSAUGA
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L5V0C9
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3050 UNION LAKE RD
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-4509
Practice Address - Country:US
Practice Address - Phone:248-363-4392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-24
Last Update Date:2019-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411812183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist