Provider Demographics
NPI:1063884112
Name:SHANGRAW, THERESA (RPH)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:SHANGRAW
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10212 ROUTE 116
Mailing Address - Street 2:
Mailing Address - City:HINESBURG
Mailing Address - State:VT
Mailing Address - Zip Code:05461-9725
Mailing Address - Country:US
Mailing Address - Phone:802-482-4886
Mailing Address - Fax:
Practice Address - Street 1:10212 ROUTE 116
Practice Address - Street 2:
Practice Address - City:HINESBURG
Practice Address - State:VT
Practice Address - Zip Code:05461-9725
Practice Address - Country:US
Practice Address - Phone:802-482-4886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0003363183500000X
CTPCT.008449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist