Provider Demographics
NPI:1235677253
Name:SHIROMA, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SHIROMA
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 1:22550 SAVI RANCH PKWY
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-4670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22550 SAVI RANCH PKWY
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92887-4670
Practice Address - Country:US
Practice Address - Phone:714-685-3580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH41092183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist