Provider Demographics
NPI:1174192785
Name:SECRETO, SHANNA RAE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNA
Middle Name:RAE
Last Name:SECRETO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MRS
Other - First Name:SHANNA
Other - Middle Name:RAE
Other - Last Name:MAXWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:208 GIANT ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-2440
Mailing Address - Country:US
Mailing Address - Phone:304-599-2369
Mailing Address - Fax:
Practice Address - Street 1:208 GIANT ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-2440
Practice Address - Country:US
Practice Address - Phone:304-599-2369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist