Provider Demographics
NPI:1164791869
Name:SHIN, HA
Entity Type:Individual
Prefix:
First Name:HA
Middle Name:
Last Name:SHIN
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 1:1124 TOWN COLONY DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5923
Mailing Address - Country:US
Mailing Address - Phone:774-239-5639
Mailing Address - Fax:
Practice Address - Street 1:1124 TOWN COLONY DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-5923
Practice Address - Country:US
Practice Address - Phone:774-239-5639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-26
Last Update Date:2011-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT0012082183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist