Provider Demographics
NPI:1396340089
Name:SHETTY, VIDYA
Entity type:Individual
Prefix:
First Name:VIDYA
Middle Name:
Last Name:SHETTY
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 1:27 COLMART WAY # 27
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-5594
Mailing Address - Country:US
Mailing Address - Phone:848-219-9041
Mailing Address - Fax:
Practice Address - Street 1:230 MILLTOWN RD
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-2553
Practice Address - Country:US
Practice Address - Phone:908-231-6360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03045600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist