Provider Demographics
NPI:1407217474
Name:SHAW, THEODORE D
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:D
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 1:476 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:HANSON
Mailing Address - State:MA
Mailing Address - Zip Code:02341-1163
Mailing Address - Country:US
Mailing Address - Phone:781-293-0561
Mailing Address - Fax:781-293-0529
Practice Address - Street 1:476 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:HANSON
Practice Address - State:MA
Practice Address - Zip Code:02341-1163
Practice Address - Country:US
Practice Address - Phone:781-293-0561
Practice Address - Fax:781-293-0529
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH23356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist