Provider Demographics
NPI:1912189010
Name:NELSON, SHIREEN R (RPH)
Entity Type:Individual
Prefix:
First Name:SHIREEN
Middle Name:R
Last Name:NELSON
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 1:13 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5437
Mailing Address - Country:US
Mailing Address - Phone:516-797-0080
Mailing Address - Fax:
Practice Address - Street 1:400 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4207
Practice Address - Country:US
Practice Address - Phone:631-951-0805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01796161Medicaid