Healthcare Provider Details

I. General information

NPI: 1932743077
Provider Name (Legal Business Name): SHANE F FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 WHEELING AVE
CAMBRIDGE OH
43725-2441
US

IV. Provider business mailing address

915 TAYLOR AVE
CAMBRIDGE OH
43725-1530
US

V. Phone/Fax

Practice location:
  • Phone: 740-432-9301
  • Fax:
Mailing address:
  • Phone: 724-812-2457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03439246
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: