Provider Demographics
NPI:1104111715
Name:SHADLE, SHIRLEY
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:SHADLE
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 1:19955 KATY FWY
Mailing Address - Street 2:T-0907
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77094-1019
Mailing Address - Country:US
Mailing Address - Phone:281-492-7906
Mailing Address - Fax:281-492-7906
Practice Address - Street 1:19955 KATY FWY
Practice Address - Street 2:T-0907
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77094-1019
Practice Address - Country:US
Practice Address - Phone:281-492-7906
Practice Address - Fax:281-492-7906
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist