=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710166699
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMIR K SHAH RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2007
-----------------------------------------------------
Last Update Date | 10/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 187 MILL ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12754-2000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-292-3430
-----------------------------------------------------
Fax | 845-292-3437
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 GRAND VIEW TER
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10918-8201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-469-4618
-----------------------------------------------------
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 | 048917
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------