Healthcare Provider Details

I. General information

NPI: 1023661568
Provider Name (Legal Business Name): MARY M SHOURA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5411 SUPERIOR AVE
CLEVELAND OH
44103-1344
US

IV. Provider business mailing address

1221 DOVER CENTER RD
WESTLAKE OH
44145-1318
US

V. Phone/Fax

Practice location:
  • Phone: 216-431-5643
  • Fax: 216-431-4482
Mailing address:
  • Phone: 440-212-0092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03438607
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: