=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003936535
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAY PETRO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 DOGWOOD DR
-----------------------------------------------------
City | WAYNESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30830-5445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-554-5133
-----------------------------------------------------
Fax | 706-554-0941
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 516 PINE NEEDLE RD
-----------------------------------------------------
City | WAYNESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30830-1627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-554-6086
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 18804
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 9869
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 13768
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------