Provider Demographics
NPI:1699387456
Name:FADEYI, SHANTANA JANAE (RPH)
Entity Type:Individual
Prefix:DR
First Name:SHANTANA
Middle Name:JANAE
Last Name:FADEYI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3543 SOMERSET PARK DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-7346
Mailing Address - Country:US
Mailing Address - Phone:813-380-4306
Mailing Address - Fax:
Practice Address - Street 1:4502 S ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-1704
Practice Address - Country:US
Practice Address - Phone:407-851-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52981183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist