Provider Demographics
NPI:1023661568
Name:SHOURA, MARY M
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:SHOURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 DOVER CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1318
Mailing Address - Country:US
Mailing Address - Phone:440-212-0092
Mailing Address - Fax:
Practice Address - Street 1:5411 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-1344
Practice Address - Country:US
Practice Address - Phone:216-431-5643
Practice Address - Fax:216-431-4482
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03438607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist