Provider Demographics
NPI:1326679994
Name:GEORGE, SHINY T
Entity Type:Individual
Prefix:
First Name:SHINY
Middle Name:T
Last Name:GEORGE
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 1:3864 FAWN DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48306-1030
Mailing Address - Country:US
Mailing Address - Phone:248-881-7917
Mailing Address - Fax:
Practice Address - Street 1:46850 ROMEO PLANK RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-3545
Practice Address - Country:US
Practice Address - Phone:586-412-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037279183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist