Provider Demographics
NPI:1083747331
Name:SHULTS, MARY C
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:SHULTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0190
Mailing Address - Country:US
Mailing Address - Phone:509-865-2395
Mailing Address - Fax:
Practice Address - Street 1:2158 EXCHANGE ST STE 304
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3307
Practice Address - Country:US
Practice Address - Phone:503-325-8315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5623183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist