Provider Demographics
NPI:1235733742
Name:SHEA-FAUST, TREVA
Entity Type:Individual
Prefix:
First Name:TREVA
Middle Name:
Last Name:SHEA-FAUST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TREVA
Other - Middle Name:
Other - Last Name:SHEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:121 STARLING DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35756-7201
Mailing Address - Country:US
Mailing Address - Phone:239-595-6636
Mailing Address - Fax:
Practice Address - Street 1:8470 HIGHWAY 72 W
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-9575
Practice Address - Country:US
Practice Address - Phone:256-837-3362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17405183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist