Provider Demographics
NPI:1609217975
Name:OFFUTT, SHAVON MICHELLE (SRCPHT)
Entity Type:Individual
Prefix:MISS
First Name:SHAVON
Middle Name:MICHELLE
Last Name:OFFUTT
Suffix:
Gender:F
Credentials:SRCPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-2064
Mailing Address - Country:US
Mailing Address - Phone:502-585-3239
Mailing Address - Fax:502-583-3162
Practice Address - Street 1:990 BAXTER AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-2064
Practice Address - Country:US
Practice Address - Phone:502-585-3239
Practice Address - Fax:502-583-3162
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY320101050741830183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician