Provider Demographics
NPI:1548552862
Name:VALLABH, JEETEEN BHUPANDRA
Entity type:Individual
Prefix:MR
First Name:JEETEEN
Middle Name:BHUPANDRA
Last Name:VALLABH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E CHAMPLAIN DR
Mailing Address - Street 2:APT 102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-5085
Mailing Address - Country:US
Mailing Address - Phone:559-312-0174
Mailing Address - Fax:
Practice Address - Street 1:4593 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-2540
Practice Address - Country:US
Practice Address - Phone:559-222-2472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65137183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist