Healthcare Provider Details

I. General information

NPI: 1083720494
Provider Name (Legal Business Name): SHAVER HOLDINGS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 S 4TH AVE
POCATELLO ID
83201-6438
US

IV. Provider business mailing address

235 S 4TH AVE
POCATELLO ID
83201-6438
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-3341
  • Fax: 208-233-3343
Mailing address:
  • Phone: 208-233-3341
  • Fax: 208-233-3343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPHA-MOP-LIC-16394
License Number StateMT
# 7
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2104RP
License Number StateID

VIII. Authorized Official

Name: LORRI SHAVER
Title or Position: OWNER
Credential: RPH
Phone: 208-235-7244