Healthcare Provider Details

I. General information

NPI: 1124116355
Provider Name (Legal Business Name): LARRY WAYNE SHIVELY BS PHARMACY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 02/01/2024
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5TH AND ROOSEVELT 119
HINES IL
60141
US

IV. Provider business mailing address

5TH AND ROOSEVELT
HINES IL
60141
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-8387
  • Fax:
Mailing address:
  • Phone: 708-202-8387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number040875
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: