Provider Demographics
NPI:1750982500
Name:PATEL, JAY
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:PATEL
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 1:1795 PORTERTON WAY
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9570
Mailing Address - Country:US
Mailing Address - Phone:865-384-8651
Mailing Address - Fax:
Practice Address - Street 1:1500 MARKET PLACE BLVD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6060
Practice Address - Country:US
Practice Address - Phone:770-887-9325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH020629183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist