Provider Demographics
NPI:1265188577
Name:TICE, SHELBY
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:TICE
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 1:746 NE 16TH TER
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-2967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3090 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33311-1228
Practice Address - Country:US
Practice Address - Phone:954-717-1848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS63363183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist