Provider Demographics
NPI:1396926390
Name:SHEA, VICTORIA (RPH,MBA)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:SHEA
Suffix:
Gender:F
Credentials:RPH,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-4314
Mailing Address - Country:US
Mailing Address - Phone:631-663-3772
Mailing Address - Fax:
Practice Address - Street 1:577 LARKFIELD RD
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-4203
Practice Address - Country:US
Practice Address - Phone:631-368-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-18
Last Update Date:2007-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist