Provider Demographics
NPI:1255071452
Name:JARABA PENA, SHIRLEY TATIANA
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:TATIANA
Last Name:JARABA PENA
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 1:1621 GREATE RD
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER PT
Mailing Address - State:VA
Mailing Address - Zip Code:23062-2225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1309 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2832
Practice Address - Country:US
Practice Address - Phone:757-229-0962
Practice Address - Fax:757-220-2383
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202220243183500000X
TX69754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist