Provider Demographics
NPI:1588170559
Name:SHAH, SANJAY (RPH)
Entity type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 BRENTWOOD CLUB CV
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3354
Mailing Address - Country:US
Mailing Address - Phone:407-310-1623
Mailing Address - Fax:
Practice Address - Street 1:422 BRENTWOOD CLUB CV
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-3354
Practice Address - Country:US
Practice Address - Phone:407-310-1623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS36349183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist