=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124116355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY WAYNE SHIVELY BS PHARMACY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 02/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5TH AND ROOSEVELT 119
-----------------------------------------------------
City | HINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-202-8387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5TH AND ROOSEVELT
-----------------------------------------------------
City | HINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-202-8387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 040875
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------