Provider Demographics
NPI:1346626165
Name:SHAW, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:SHAW
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 1:1045 SAINT LOUIS STREET
Mailing Address - Street 2:WALGREENS 12417
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501
Mailing Address - Country:US
Mailing Address - Phone:870-307-0262
Mailing Address - Fax:
Practice Address - Street 1:1045 SAINT LOUIS STREET
Practice Address - Street 2:WALGREENS 12417
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501
Practice Address - Country:US
Practice Address - Phone:870-307-0262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD09209183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist