Provider Demographics
NPI:1528404738
Name:KERIACOUS, SHENOUDA A (RPH)
Entity Type:Individual
Prefix:
First Name:SHENOUDA
Middle Name:A
Last Name:KERIACOUS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 MICKELBERRY RD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8302
Mailing Address - Country:US
Mailing Address - Phone:480-363-5525
Mailing Address - Fax:360-308-2125
Practice Address - Street 1:4502 E OAK ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-2411
Practice Address - Country:US
Practice Address - Phone:602-808-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS017054183500000X
WAPH606315901835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist