Provider Demographics
NPI:1619194263
Name:MCINTOSH, SHADREKA T (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHADREKA
Middle Name:T
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3891 BURRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-8044
Mailing Address - Country:US
Mailing Address - Phone:239-826-4192
Mailing Address - Fax:
Practice Address - Street 1:3510 DR MARTIN LUTHER KING BLVD
Practice Address - Street 2:STE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-4608
Practice Address - Country:US
Practice Address - Phone:239-826-4192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39367183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist