Provider Demographics
NPI:1326917287
Name:PHILLIPS, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:PHILLIPS
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 1:125 FORTS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2215 BURDETT AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2466
Practice Address - Country:US
Practice Address - Phone:518-271-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-30
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064679183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist