Provider Demographics
NPI:1467691113
Name:HONEYCUTT, SHADE WILSON
Entity Type:Individual
Prefix:MR
First Name:SHADE
Middle Name:WILSON
Last Name:HONEYCUTT
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 1:211 PROVIDENCE RD STE 15
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-4687
Mailing Address - Country:US
Mailing Address - Phone:757-424-2240
Mailing Address - Fax:757-424-3632
Practice Address - Street 1:211 PROVIDENCE RD STE 15
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23325-4687
Practice Address - Country:US
Practice Address - Phone:757-424-2240
Practice Address - Fax:757-424-3632
Is Sole Proprietor?:No
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201003093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008518688Medicaid