Provider Demographics
NPI:1508079450
Name:BRANCH, SHASTA A
Entity Type:Individual
Prefix:MRS
First Name:SHASTA
Middle Name:A
Last Name:BRANCH
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 1:3152 RIVER MEADOW CIR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2334
Mailing Address - Country:US
Mailing Address - Phone:734-495-3092
Mailing Address - Fax:
Practice Address - Street 1:3152 RIVER MEADOW CIR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2334
Practice Address - Country:US
Practice Address - Phone:734-495-3092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist