Provider Demographics
NPI:1417743063
Name:MEHTA, SHIVANI (PHARMD)
Entity type:Individual
Prefix:
First Name:SHIVANI
Middle Name:
Last Name:MEHTA
Suffix:
Gender:
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 NW MADISON ST APT 228
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-3925
Mailing Address - Country:US
Mailing Address - Phone:352-587-4335
Mailing Address - Fax:
Practice Address - Street 1:780 SE BAYA DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5403
Practice Address - Country:US
Practice Address - Phone:386-755-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS65335183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist