1629324462 NPI number — KELLI KRISTINE SHAW PHARMD

Table of content: KELLI KRISTINE SHAW PHARMD (NPI 1629324462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629324462 NPI number — KELLI KRISTINE SHAW PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
KELLI
Provider Middle Name:
KRISTINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629324462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7461 BLACKMON RD
Provider Second Line Business Mailing Address:
APT. #5108
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31909-8400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-826-7851
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 CENTER ST
Provider Second Line Business Practice Location Address:
DEPARTMENT OF PHARMACY
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31901-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-571-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  1-15190 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)