Provider Demographics
NPI:1851617773
Name:SHRIVER, SHANI LEE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHANI
Middle Name:LEE
Last Name:SHRIVER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:SHANI
Other - Middle Name:LEE
Other - Last Name:BJERKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24760 HOSPTIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671
Mailing Address - Country:US
Mailing Address - Phone:218-679-3912
Mailing Address - Fax:218-679-0189
Practice Address - Street 1:24760 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-3912
Practice Address - Fax:218-679-0189
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1198061835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN119806OtherPHARMACIST LICENSE