Provider Demographics
NPI:1336211135
Name:SHADY MED INC
Entity type:Organization
Organization Name:SHADY MED INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEFFLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-417-9861
Mailing Address - Street 1:5020 CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213
Mailing Address - Country:US
Mailing Address - Phone:412-586-5410
Mailing Address - Fax:412-586-5351
Practice Address - Street 1:5020 CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213
Practice Address - Country:US
Practice Address - Phone:412-586-5410
Practice Address - Fax:412-586-5351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP414789L183500000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014239230003Medicaid
3967114OtherOTHER ID NUMBER
3967114OtherOTHER ID NUMBER