Provider Demographics
NPI:1023573763
Name:SHEHATA, PETER B
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:B
Last Name:SHEHATA
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 1:17860 SE 109TH AVE STE 616A
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-8909
Mailing Address - Country:US
Mailing Address - Phone:352-775-0888
Mailing Address - Fax:352-775-0909
Practice Address - Street 1:17860 SE 109TH AVE STE 616A
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8909
Practice Address - Country:US
Practice Address - Phone:352-775-0888
Practice Address - Fax:352-775-0909
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS47518183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty