Healthcare Provider Details

I. General information

NPI: 1639806458
Provider Name (Legal Business Name): BRIAN SHADBOLT PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

397 SUNRISE HWY W
PATCHOGUE NY
11772-1901
US

IV. Provider business mailing address

120A MULFORD ST
PATCHOGUE NY
11772-8615
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-1300
  • Fax:
Mailing address:
  • Phone: 516-356-3202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number069231
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: