Provider Demographics
NPI:1912249434
Name:HOEKWATER, SHANE MICHAEL
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:HOEKWATER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4375 SAINT CHARLES PL
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-3458
Mailing Address - Country:US
Mailing Address - Phone:925-899-2814
Mailing Address - Fax:
Practice Address - Street 1:4375 SAINT CHARLES PL
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94521-3458
Practice Address - Country:US
Practice Address - Phone:925-899-2814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87306183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician