=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619520285
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIDHARTH PATEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2019
-----------------------------------------------------
Last Update Date | 07/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2431 S HIGLEY RD
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-988-4326
-----------------------------------------------------
Fax | 480-988-7464
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4048 E TOLEDO ST UNIT 104
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-0172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-353-0006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | S024043
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------