Provider Demographics
NPI:1497056261
Name:SHAFFER, BREANNA (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:BREANNA
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2259 MAPLEROW AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-2708
Mailing Address - Country:US
Mailing Address - Phone:616-307-5106
Mailing Address - Fax:
Practice Address - Street 1:5500 CLYDE PARK AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9525
Practice Address - Country:US
Practice Address - Phone:616-531-9629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13120183500000X
MI5302037046183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist