Provider Demographics
NPI:1053912352
Name:SHAH, MANSI ROCKY
Entity type:Individual
Prefix:
First Name:MANSI
Middle Name:ROCKY
Last Name:SHAH
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 1:723 WATERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-3718
Mailing Address - Country:US
Mailing Address - Phone:630-550-3789
Mailing Address - Fax:
Practice Address - Street 1:150 SMITH RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5204
Practice Address - Country:US
Practice Address - Phone:630-513-9560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292376183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist