Provider Demographics
NPI:1235415308
Name:GARRETT, SHANA R
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:R
Last Name:GARRETT
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 1:124 TIDES RUN
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-4333
Mailing Address - Country:US
Mailing Address - Phone:402-291-6585
Mailing Address - Fax:
Practice Address - Street 1:919 W MERCURY BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-4322
Practice Address - Country:US
Practice Address - Phone:757-827-2995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202210269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist