Provider Demographics
NPI:1609412733
Name:SHAFER, WILLIAM J
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:SHAFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2658 PEBBLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48363-2449
Mailing Address - Country:US
Mailing Address - Phone:248-229-4042
Mailing Address - Fax:
Practice Address - Street 1:16450 26 MILE RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-1056
Practice Address - Country:US
Practice Address - Phone:586-677-8730
Practice Address - Fax:586-677-8735
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist