Provider Demographics
NPI:1992129308
Name:SHABASHOV, MARK (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SHABASHOV
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 1:108 ROYAL SAINT GEORGES WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-5642
Mailing Address - Country:US
Mailing Address - Phone:951-805-4507
Mailing Address - Fax:
Practice Address - Street 1:42150 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-9611
Practice Address - Country:US
Practice Address - Phone:706-020-0084
Practice Address - Fax:760-200-0573
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33172183500000X
AZS007040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist