Provider Demographics
NPI:1063813541
Name:MATHAI, SHAILA
Entity Type:Individual
Prefix:
First Name:SHAILA
Middle Name:
Last Name:MATHAI
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 1:4086 S LIVERPOOL WAY
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-7461
Mailing Address - Country:US
Mailing Address - Phone:850-570-2144
Mailing Address - Fax:
Practice Address - Street 1:16601 E CENTRETECH PKWY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-9045
Practice Address - Country:US
Practice Address - Phone:303-344-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA0019640183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist