Provider Demographics
NPI:1447896345
Name:MISTRY, HITESH MANHARLAL
Entity type:Individual
Prefix:
First Name:HITESH
Middle Name:MANHARLAL
Last Name:MISTRY
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 1:8301 LIONSGATE RUN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-4715
Mailing Address - Country:US
Mailing Address - Phone:260-515-8388
Mailing Address - Fax:
Practice Address - Street 1:929 S 13TH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-1805
Practice Address - Country:US
Practice Address - Phone:260-724-9187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026685A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist