Provider Demographics
NPI:1285257634
Name:SPACEK, SHANE ALLEN (PHARMACIST)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:ALLEN
Last Name:SPACEK
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ROAD 7586
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-4934
Mailing Address - Country:US
Mailing Address - Phone:505-960-7860
Mailing Address - Fax:
Practice Address - Street 1:6 ROAD 7586
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-4934
Practice Address - Country:US
Practice Address - Phone:505-960-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPH42212183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist