Provider Demographics
NPI:1083809982
Name:REGALIA, THEODORE SHAWN (RPH)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:SHAWN
Last Name:REGALIA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 OTTER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FALL CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54742-9378
Mailing Address - Country:US
Mailing Address - Phone:715-563-1586
Mailing Address - Fax:715-855-5062
Practice Address - Street 1:6725 OTTER CREEK RD
Practice Address - Street 2:
Practice Address - City:FALL CREEK
Practice Address - State:WI
Practice Address - Zip Code:54742-9378
Practice Address - Country:US
Practice Address - Phone:715-563-1586
Practice Address - Fax:715-855-5062
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10973-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist