Provider Demographics
NPI:1295339505
Name:MALEKOUTI, SHANE
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:MALEKOUTI
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 1:9107 SHORE CREST DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-6928
Mailing Address - Country:US
Mailing Address - Phone:972-415-2315
Mailing Address - Fax:
Practice Address - Street 1:107 E OVILLA RD
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-2445
Practice Address - Country:US
Practice Address - Phone:972-576-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist