Provider Demographics
NPI:1689837437
Name:PATEL, MITULKUMAR GANDABHAI
Entity type:Individual
Prefix:MR
First Name:MITULKUMAR
Middle Name:GANDABHAI
Last Name:PATEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 RIVENDELL WAY
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2010
Mailing Address - Country:US
Mailing Address - Phone:732-354-4084
Mailing Address - Fax:
Practice Address - Street 1:786 SAINT GEROGES AVE
Practice Address - Street 2:WALGREENS PHARMACY
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065
Practice Address - Country:US
Practice Address - Phone:732-499-4582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03209300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist