=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801021589
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMIR A DESAI RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2009
-----------------------------------------------------
Last Update Date | 03/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 462 GRIDER ST
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14215-3021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-332-2866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 920 NORTHWOOD DR
-----------------------------------------------------
City | WILLIAMSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14221-3855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-807-8823
-----------------------------------------------------
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 | 03071100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 052900
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------