Provider Demographics
NPI:1023776754
Name:SHAH, SHREYA
Entity type:Individual
Prefix:
First Name:SHREYA
Middle Name:
Last Name:SHAH
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 1:2700 SW WALLACE WAY APT 307
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72713-3030
Mailing Address - Country:US
Mailing Address - Phone:224-795-3290
Mailing Address - Fax:
Practice Address - Street 1:240 SLACK ST
Practice Address - Street 2:
Practice Address - City:PEA RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72751-3759
Practice Address - Country:US
Practice Address - Phone:479-451-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD15977183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist