Provider Demographics
NPI:1710770169
Name:GROTH, SHAYBRIANA (PHARMD)
Entity type:Individual
Prefix:
First Name:SHAYBRIANA
Middle Name:
Last Name:GROTH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 W HAYMEADOW PL APT 2C
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3136
Mailing Address - Country:US
Mailing Address - Phone:414-630-7572
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:414-630-7572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0513064181835P0200X
WI22474-401835P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0200XPharmacy Service ProvidersPharmacistPediatrics