Provider Demographics
NPI:1922748789
Name:SHIVELY, MERRICK LEE (PHD, RPH)
Entity Type:Individual
Prefix:
First Name:MERRICK
Middle Name:LEE
Last Name:SHIVELY
Suffix:
Gender:M
Credentials:PHD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 DIVIDE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80403-9787
Mailing Address - Country:US
Mailing Address - Phone:303-808-6401
Mailing Address - Fax:
Practice Address - Street 1:1055 DIVIDE VIEW DR
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80403-9787
Practice Address - Country:US
Practice Address - Phone:303-808-6401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO125171835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherNONE
NONEOtherNONE