Provider Demographics
NPI:1174096994
Name:SHABO, FAYA
Entity type:Individual
Prefix:
First Name:FAYA
Middle Name:
Last Name:SHABO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 COLE CT
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-1007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 COLE CT
Practice Address - Street 2:
Practice Address - City:DUMONT
Practice Address - State:NJ
Practice Address - Zip Code:07628-1007
Practice Address - Country:US
Practice Address - Phone:201-982-1446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI3920300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI03920300OtherNEW JERSEY BOARD OF PHARMACY