Healthcare Provider Details

I. General information

NPI: 1265795082
Provider Name (Legal Business Name): JAY SHREE GANESH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10124 AUBURN PARK DR
FORT WAYNE IN
46825-2392
US

IV. Provider business mailing address

10124 AUBURN PARK DR
FORT WAYNE IN
46825-2392
US

V. Phone/Fax

Practice location:
  • Phone: 260-739-7160
  • Fax: 260-739-7268
Mailing address:
  • Phone: 260-445-6741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number60006305A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BHARAT PATEL
Title or Position: OWNER
Credential:
Phone: 260-445-6741