Provider Demographics
NPI:1811669070
Name:RIESCO, SHEILA M
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:M
Last Name:RIESCO
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 1:73 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07727-1326
Mailing Address - Country:US
Mailing Address - Phone:732-938-9051
Mailing Address - Fax:
Practice Address - Street 1:1592 HORSESHOE DR
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-2704
Practice Address - Country:US
Practice Address - Phone:732-996-1979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02617900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RJ10042OtherIMMUNIZATION LICENSE