Provider Demographics
NPI:1396171179
Name:MODI, BHAUMIKKUMAR (PHARMD)
Entity type:Individual
Prefix:
First Name:BHAUMIKKUMAR
Middle Name:
Last Name:MODI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1683 N ROCKY RD
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-2500
Mailing Address - Country:US
Mailing Address - Phone:909-762-1830
Mailing Address - Fax:
Practice Address - Street 1:1301 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2910
Practice Address - Country:US
Practice Address - Phone:909-809-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist