Provider Demographics
NPI:1629288717
Name:SHAW, CLIFTON EUGENE (DPH)
Entity Type:Individual
Prefix:DR
First Name:CLIFTON
Middle Name:EUGENE
Last Name:SHAW
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6755 MAUVILLA DR W
Mailing Address - Street 2:
Mailing Address - City:EIGHT MILE
Mailing Address - State:AL
Mailing Address - Zip Code:36613-9351
Mailing Address - Country:US
Mailing Address - Phone:251-422-2500
Mailing Address - Fax:251-679-8330
Practice Address - Street 1:6400 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3702
Practice Address - Country:US
Practice Address - Phone:251-380-3188
Practice Address - Fax:251-344-5819
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7347OtherPHARMACIST REGISTRATION