=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235437005
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIGNESH MANDAVIA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2011
-----------------------------------------------------
Last Update Date | 03/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10215 MCINTYRE RIDGE RD 101
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-831-9212
-----------------------------------------------------
Fax | 704-831-9214
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3108 WEDDINGTON RD
-----------------------------------------------------
City | MATTHEWS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28105-6665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-246-6376
-----------------------------------------------------
Fax | 704-849-7206
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 17809
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 18135
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------