Provider Demographics
NPI:1134194202
Name:SHIVOAM LLC
Entity type:Organization
Organization Name:SHIVOAM LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARDIK
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-272-5944
Mailing Address - Street 1:319 S WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720
Mailing Address - Country:US
Mailing Address - Phone:386-734-3383
Mailing Address - Fax:386-734-3384
Practice Address - Street 1:319 S WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720
Practice Address - Country:US
Practice Address - Phone:386-734-3383
Practice Address - Fax:386-734-3384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH11083332B00000X, 3336C0004X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1064512OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL109020800Medicaid
FLBT2212304OtherDEA
FL109020800Medicaid