Provider Demographics
NPI:1255974069
Name:FOX, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:FOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 ALAFAYA TRL
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9410
Mailing Address - Country:US
Mailing Address - Phone:407-359-6932
Mailing Address - Fax:407-359-9717
Practice Address - Street 1:4255 ALAFAYA TRL
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9410
Practice Address - Country:US
Practice Address - Phone:407-359-6932
Practice Address - Fax:407-359-9717
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty