Provider Demographics
NPI:1659853497
Name:SHENODA, BAKHEET
Entity Type:Individual
Prefix:
First Name:BAKHEET
Middle Name:
Last Name:SHENODA
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 1:1035B PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:WHITINSVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01588-2121
Mailing Address - Country:US
Mailing Address - Phone:508-372-0627
Mailing Address - Fax:
Practice Address - Street 1:1035B PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:WHITINSVILLE
Practice Address - State:MA
Practice Address - Zip Code:01588-2121
Practice Address - Country:US
Practice Address - Phone:508-372-0627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA237672183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA237672OtherRPH LICENSE