Provider Demographics
NPI:1730479007
Name:SHIVERS, MARLON (DPH)
Entity Type:Individual
Prefix:
First Name:MARLON
Middle Name:
Last Name:SHIVERS
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 1:1493 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-3845
Mailing Address - Country:US
Mailing Address - Phone:931-551-9948
Mailing Address - Fax:
Practice Address - Street 1:1493 MADISON ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-3845
Practice Address - Country:US
Practice Address - Phone:931-551-9948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist