Provider Demographics
NPI:1396054714
Name:REDDY, SHANTAN R (PHARMACIST)
Entity type:Individual
Prefix:
First Name:SHANTAN
Middle Name:R
Last Name:REDDY
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MILO
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-943-8750
Mailing Address - Fax:207-943-5248
Practice Address - Street 1:35 PARK ST
Practice Address - Street 2:
Practice Address - City:MILO
Practice Address - State:ME
Practice Address - Zip Code:04463-1152
Practice Address - Country:US
Practice Address - Phone:207-943-8750
Practice Address - Fax:207-943-5248
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5816183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist