Provider Demographics
NPI:1972150191
Name:SHAW, MICHAEL ALFRED (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALFRED
Last Name:SHAW
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:CROWELL
Mailing Address - State:TX
Mailing Address - Zip Code:79227-0129
Mailing Address - Country:US
Mailing Address - Phone:940-684-1581
Mailing Address - Fax:940-684-1860
Practice Address - Street 1:102 E COMMERCE
Practice Address - Street 2:
Practice Address - City:CROWELL
Practice Address - State:TX
Practice Address - Zip Code:79227
Practice Address - Country:US
Practice Address - Phone:940-684-1581
Practice Address - Fax:940-684-1860
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19719183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist