Provider Demographics
NPI:1285954784
Name:SHAW, MARK A (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:SHAW
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36975 PRICE RD
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-8889
Mailing Address - Country:US
Mailing Address - Phone:740-385-7621
Mailing Address - Fax:
Practice Address - Street 1:40 WATKINS ST
Practice Address - Street 2:
Practice Address - City:NELSONVILLE
Practice Address - State:OH
Practice Address - Zip Code:45764
Practice Address - Country:US
Practice Address - Phone:740-753-2484
Practice Address - Fax:740-753-4815
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03213924183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist