Provider Demographics
NPI:1548779804
Name:BRACEWELL, SHANE (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:BRACEWELL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1863
Mailing Address - Street 2:
Mailing Address - City:BARROW
Mailing Address - State:AK
Mailing Address - Zip Code:99723-1863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7000 UULA ST
Practice Address - Street 2:
Practice Address - City:BARROW
Practice Address - State:AK
Practice Address - Zip Code:99723
Practice Address - Country:US
Practice Address - Phone:907-852-9277
Practice Address - Fax:907-852-4237
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH237620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist