Provider Demographics
NPI:1942614243
Name:TADRES, SHAWILL
Entity Type:Individual
Prefix:
First Name:SHAWILL
Middle Name:
Last Name:TADRES
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 1:1688 N PERRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-4709
Mailing Address - Country:US
Mailing Address - Phone:951-943-6868
Mailing Address - Fax:
Practice Address - Street 1:1688 N PERRIS BLVD
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-4709
Practice Address - Country:US
Practice Address - Phone:951-943-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist