Healthcare Provider Details

I. General information

NPI: 1558846329
Provider Name (Legal Business Name): KOMAL K PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 WOODHAVEN RD
PHILADELPHIA PA
19154-2810
US

IV. Provider business mailing address

1856 GARTH RD
PHILADELPHIA PA
19116-3828
US

V. Phone/Fax

Practice location:
  • Phone: 215-637-7840
  • Fax:
Mailing address:
  • Phone: 215-764-9287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP452452
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: