Provider Demographics
NPI:1215413026
Name:TAVASSOLI, SHIVA SHILA
Entity Type:Individual
Prefix:
First Name:SHIVA
Middle Name:SHILA
Last Name:TAVASSOLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 AMBER LEAF DR
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29341-3552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 LOCUST ST
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:SC
Practice Address - Zip Code:29365
Practice Address - Country:US
Practice Address - Phone:864-439-1040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-15
Last Update Date:2018-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist