=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790663797
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVA ELISABETH SHIMKUS PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2025
-----------------------------------------------------
Last Update Date | 08/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 HOLLAND AVE # 119
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12208-3410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-626-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 192 SPRING RD
-----------------------------------------------------
City | GLENVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12302-3832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-545-1014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 073012
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------