Healthcare Provider Details

I. General information

NPI: 1659762987
Provider Name (Legal Business Name): SHEENA THOMAS KOTTACKAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1453 MEADOW VISTA DR
CARROLLTON TX
75007
US

IV. Provider business mailing address

1453 MEADOW VISTA DR
CARROLLTON TX
75007-6046
US

V. Phone/Fax

Practice location:
  • Phone: 518-229-1368
  • Fax:
Mailing address:
  • Phone: 518-229-1368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number64175
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number059619
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: