Provider Demographics
NPI:1902021132
Name:MEHTA, SANDEEP MAGANLAL (RPH)
Entity Type:Individual
Prefix:MR
First Name:SANDEEP
Middle Name:MAGANLAL
Last Name:MEHTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1039 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-1533
Mailing Address - Country:US
Mailing Address - Phone:269-841-5656
Mailing Address - Fax:269-841-5656
Practice Address - Street 1:955 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9701
Practice Address - Country:US
Practice Address - Phone:269-639-2858
Practice Address - Fax:269-639-2860
Is Sole Proprietor?:No
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035514183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist