Provider Demographics
NPI:1205137361
Name:SHIVELY, ELIZABETH JEAN (RPH)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:JEAN
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:ELIZABETH
Other - Middle Name:LEWIS
Other - Last Name:SHIVELY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:3931 CYNTHIA DR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-2399
Mailing Address - Country:US
Mailing Address - Phone:307-277-5700
Mailing Address - Fax:307-234-0393
Practice Address - Street 1:1375 CY AVE
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-3513
Practice Address - Country:US
Practice Address - Phone:307-234-7949
Practice Address - Fax:307-234-0393
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2206183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist