MEDICARE: SHIRLEY TATIANA JARABA PENA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0202220243	VA
2	183500000X	Pharmacist	69754	TX

General Provider Information

NPI Number	:	1255071452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIRLEY TATIANA JARABA PENA

Provider Business Mailing Address
First Line	:	1621 GREATE RD
Second Line	:
City	:	GLOUCESTER PT
State	:	VA
Zip	:	23062-2225
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1309 RICHMOND RD
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23185-2832
Country	:	US
Telephone Number	:	757-229-0962
Fax Number	:	757-220-2383

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2022
Last Update Date	:	01/05/2023

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