Provider Demographics
NPI:1437771110
Name:GLAM SHOP BY ANITRA SHAREE LLC
Entity Type:Organization
Organization Name:GLAM SHOP BY ANITRA SHAREE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HAIR LOSS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANITRA
Authorized Official - Middle Name:NASH
Authorized Official - Last Name:PHIFER
Authorized Official - Suffix:
Authorized Official - Credentials:HAIR LOSS SPECIALIST
Authorized Official - Phone:704-923-1469
Mailing Address - Street 1:3306 TABLE ROCK DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-5437
Mailing Address - Country:US
Mailing Address - Phone:704-923-1469
Mailing Address - Fax:
Practice Address - Street 1:2483 E OZARK AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1421
Practice Address - Country:US
Practice Address - Phone:704-923-1469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-15
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty