Provider Demographics
NPI:1710454913
Name:HUMASON, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:HUMASON
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 1:1701 E MAPLE ST APT 206
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-2850
Mailing Address - Country:US
Mailing Address - Phone:785-312-2878
Mailing Address - Fax:
Practice Address - Street 1:1225 EAST SUNSET DRIVE, STE 110
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226
Practice Address - Country:US
Practice Address - Phone:360-671-5041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60879286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist