Provider Demographics
NPI:1134766595
Name:PATEL, MAMTA PRADIP (PHARMD)
Entity type:Individual
Prefix:
First Name:MAMTA
Middle Name:PRADIP
Last Name:PATEL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33980-4214
Mailing Address - Country:US
Mailing Address - Phone:941-629-1512
Mailing Address - Fax:
Practice Address - Street 1:9305 RIVER OTTER DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-8925
Practice Address - Country:US
Practice Address - Phone:423-774-0142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS47419183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist