Provider Demographics
NPI:1659762987
Name:KOTTACKAL, SHEENA THOMAS
Entity Type:Individual
Prefix:
First Name:SHEENA
Middle Name:THOMAS
Last Name:KOTTACKAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 MEADOW VISTA DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-6046
Mailing Address - Country:US
Mailing Address - Phone:518-229-1368
Mailing Address - Fax:
Practice Address - Street 1:1453 MEADOW VISTA DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007
Practice Address - Country:US
Practice Address - Phone:518-229-1368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64175183500000X
NY059619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist