Healthcare Provider Details

I. General information

NPI: 1669562542
Provider Name (Legal Business Name): DIANE JILL SHAWA CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 S. MAIN ST.
EATON RAPIDS MI
48827
US

IV. Provider business mailing address

407 E ELIZABETH ST
EATON RAPIDS MI
48827
US

V. Phone/Fax

Practice location:
  • Phone: 517-663-8331
  • Fax: 517-663-0010
Mailing address:
  • Phone: 517-663-6472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number210118142753913
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: