Provider Demographics
NPI:1528467834
Name:SIDDIQI, SHAN ALI (PHARMD)
Entity type:Individual
Prefix:
First Name:SHAN ALI
Middle Name:
Last Name:SIDDIQI
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 1:11521 JASPER DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-9141
Mailing Address - Country:US
Mailing Address - Phone:586-489-1409
Mailing Address - Fax:
Practice Address - Street 1:4885 ELDORADO PKWY
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-8662
Practice Address - Country:US
Practice Address - Phone:972-464-5745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55585183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist