Provider Demographics
NPI:1275938821
Name:TAWADROUS, SHADY MAHROUS JOHN
Entity Type:Individual
Prefix:
First Name:SHADY
Middle Name:MAHROUS JOHN
Last Name:TAWADROUS
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 1:2928 BANCROFT CIR E
Mailing Address - Street 2:APT F
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-2536
Mailing Address - Country:US
Mailing Address - Phone:727-437-9538
Mailing Address - Fax:
Practice Address - Street 1:2928 BANCROFT CIR E
Practice Address - Street 2:APT F
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-2536
Practice Address - Country:US
Practice Address - Phone:727-437-9538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS51531183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist