Provider Demographics
NPI:1003936535
Name:PETRO, SHAY
Entity Type:Individual
Prefix:
First Name:SHAY
Middle Name:
Last Name:PETRO
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 1:516 PINE NEEDLE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30830-1627
Mailing Address - Country:US
Mailing Address - Phone:706-554-6086
Mailing Address - Fax:
Practice Address - Street 1:201 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:GA
Practice Address - Zip Code:30830-5445
Practice Address - Country:US
Practice Address - Phone:706-554-5133
Practice Address - Fax:706-554-0941
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA18804183500000X
TN9869183500000X
NC13768183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist