Provider Demographics
NPI:1255676862
Name:SHAPAZIAN, JERRY MARTIN
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:MARTIN
Last Name:SHAPAZIAN
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 1:1870 COSTA BRAVA
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3332
Mailing Address - Country:US
Mailing Address - Phone:805-709-2971
Mailing Address - Fax:
Practice Address - Street 1:1051 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2504
Practice Address - Country:US
Practice Address - Phone:805-481-1961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist