=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689837437
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. MITULKUMAR GANDABHAI PATEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2008
-----------------------------------------------------
Last Update Date | 07/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 786 SAINT GEROGES AVE WALGREENS PHARMACY
-----------------------------------------------------
City | RAHWAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-499-4582
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 RIVENDELL WAY
-----------------------------------------------------
City | EDISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08817-2010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-354-4084
-----------------------------------------------------
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 | 28RI03209300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------