Provider Demographics
NPI:1851871701
Name:RYAN, SHEA PETER (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHEA
Middle Name:PETER
Last Name:RYAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE, DEPT OF PHARMACY
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642
Mailing Address - Country:US
Mailing Address - Phone:585-275-5212
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE, DEPT OF PHARMACY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642
Practice Address - Country:US
Practice Address - Phone:585-275-5212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR69231183500000X
IL051301280183500000X
NY069026183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY069026OtherSTATE LICENSE
MEPR69231OtherSTATE LICENSE
IL051301280OtherSTATE LICENSE