Provider Demographics
NPI:1609527258
Name:SHIELDS, MADISON ERIN
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ERIN
Last Name:SHIELDS
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 1:6735 LINDERSON WAY SW UNIT E203
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-6520
Mailing Address - Country:US
Mailing Address - Phone:619-820-7156
Mailing Address - Fax:
Practice Address - Street 1:1200 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1853
Practice Address - Country:US
Practice Address - Phone:360-807-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61182338183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist