Provider Demographics
NPI:1083203483
Name:SHANAD, GERGES B
Entity Type:Individual
Prefix:
First Name:GERGES
Middle Name:B
Last Name:SHANAD
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 1:360 21ST CT SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-3368
Mailing Address - Country:US
Mailing Address - Phone:772-713-9131
Mailing Address - Fax:772-918-8783
Practice Address - Street 1:13260 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3750
Practice Address - Country:US
Practice Address - Phone:772-571-6496
Practice Address - Fax:772-918-8783
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS36454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist