Provider Demographics
NPI:1861145559
Name:PANDYA, SANJIV
Entity type:Individual
Prefix:MR
First Name:SANJIV
Middle Name:
Last Name:PANDYA
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 1:254 E HARVARD BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA PAULA
Mailing Address - State:CA
Mailing Address - Zip Code:93060-3372
Mailing Address - Country:US
Mailing Address - Phone:805-525-8700
Mailing Address - Fax:805-525-8711
Practice Address - Street 1:254 E HARVARD BLVD
Practice Address - Street 2:
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-3372
Practice Address - Country:US
Practice Address - Phone:805-525-8700
Practice Address - Fax:805-525-8711
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47063183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1821396227Medicaid