Healthcare Provider Details

I. General information

NPI: 1285851733
Provider Name (Legal Business Name): VANDANKUMAR JAGADISHCHANDRA PATHAK PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 ELECTRIC RD
SALEM VA
24153-7474
US

IV. Provider business mailing address

3816 SUNSCAPE DR APT# 408
ROANOKE VA
24018-3175
US

V. Phone/Fax

Practice location:
  • Phone: 540-776-4130
  • Fax: 540-776-4982
Mailing address:
  • Phone: 540-989-0518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202205879
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16156
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: