Provider Demographics
NPI:1487203972
Name:COVINGTON, SHANELLE
Entity Type:Individual
Prefix:
First Name:SHANELLE
Middle Name:
Last Name:COVINGTON
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 1:7490 HAGGERTY RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1067
Mailing Address - Country:US
Mailing Address - Phone:248-661-4409
Mailing Address - Fax:
Practice Address - Street 1:7490 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-1067
Practice Address - Country:US
Practice Address - Phone:248-661-4409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302046965183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist