Healthcare Provider Details

I. General information

NPI: 1144795220
Provider Name (Legal Business Name): AJAYKUMAR PATEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 BRIDGER DR
GREEN RIVER WY
82935-5879
US

IV. Provider business mailing address

8279 S LANCE ST APT 17
MIDVALE UT
84047-7287
US

V. Phone/Fax

Practice location:
  • Phone: 307-875-7841
  • Fax:
Mailing address:
  • Phone: 201-920-2840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberTL3829
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: