=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811613235
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLGA SHIMUNOVA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2022
-----------------------------------------------------
Last Update Date | 10/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4101 TOWNE CENTER DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40241-4146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-214-2440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 309 PALAZZO CIR APT 211
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40222-5697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-348-8939
-----------------------------------------------------
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 | 020873
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------