Provider Demographics
NPI:1750803169
Name:PAVITRAM, SHYLAJA
Entity type:Individual
Prefix:
First Name:SHYLAJA
Middle Name:
Last Name:PAVITRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 RIEDER RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1018 US HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:PARLIN
Practice Address - State:NJ
Practice Address - Zip Code:08859-1401
Practice Address - Country:US
Practice Address - Phone:732-561-3339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03277700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist