Healthcare Provider Details

I. General information

NPI: 1336494301
Provider Name (Legal Business Name): MRS. PRATIMA KEJRIWAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MOORPARK AVE 101
SAN JOSE CA
95128-2631
US

IV. Provider business mailing address

2400 MOORPARK AVE 101
SAN JOSE CA
95128-2631
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-7695
  • Fax: 408-885-7690
Mailing address:
  • Phone: 408-885-7695
  • Fax: 408-885-7690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number47122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: