Provider Demographics
NPI:1396232419
Name:ST MARTIN, SHIVANI
Entity Type:Individual
Prefix:
First Name:SHIVANI
Middle Name:
Last Name:ST MARTIN
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 1:409 FULTON ST LOT A
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:NY
Mailing Address - Zip Code:13074-3300
Mailing Address - Country:US
Mailing Address - Phone:315-564-6575
Mailing Address - Fax:
Practice Address - Street 1:409 FULTON ST LOT A
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:NY
Practice Address - Zip Code:13074-3300
Practice Address - Country:US
Practice Address - Phone:315-564-6575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063889183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist