Provider Demographics
NPI:1346223682
Name:NYE, SHANE M (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:NYE
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 1:871 BLUE GOOSE RD
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953-9190
Mailing Address - Country:US
Mailing Address - Phone:590-865-2311
Mailing Address - Fax:
Practice Address - Street 1:401 BUSTER RD
Practice Address - Street 2:YAKAMA INDIAN HEALTH CENTER
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948
Practice Address - Country:US
Practice Address - Phone:509-862-1703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5664130-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist