Provider Demographics
NPI:1710581830
Name:SHADY, CONNIE (RPH)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:SHADY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 BEECH ST APT 105
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-6396
Mailing Address - Country:US
Mailing Address - Phone:260-547-4106
Mailing Address - Fax:
Practice Address - Street 1:907 S HEATON ST
Practice Address - Street 2:
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-2044
Practice Address - Country:US
Practice Address - Phone:574-772-6544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013743A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist