Provider Demographics
NPI:1306023684
Name:WOOLF, SHANE WILTON (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:WILTON
Last Name:WOOLF
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7428 EAGLE CREST AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2187
Mailing Address - Country:US
Mailing Address - Phone:505-385-5885
Mailing Address - Fax:
Practice Address - Street 1:8011 HARPER DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1054
Practice Address - Country:US
Practice Address - Phone:505-217-2392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist