Provider Demographics
NPI:1083720494
Name:SHAVER HOLDINGS INC
Entity Type:Organization
Organization Name:SHAVER HOLDINGS INC
Other - Org Name:SHAVER PHARMACY AND COMPOUNDING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORRI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAVER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-235-7244
Mailing Address - Street 1:235 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6438
Mailing Address - Country:US
Mailing Address - Phone:208-233-3341
Mailing Address - Fax:208-233-3343
Practice Address - Street 1:235 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6438
Practice Address - Country:US
Practice Address - Phone:208-233-3341
Practice Address - Fax:208-233-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-MOP-LIC-16394332B00000X
332BX2000X, 333600000X, 3336C0004X, 3336M0003X, 3336S0011X
ID2104RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1083720494Medicaid
2021940OtherPK
5748320001Medicare NSC