Provider Demographics
NPI:1649583683
Name:SHAW, ALICE
Entity type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:
Last Name:SHAW
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 1:81 SADDLEBACK RD
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90274-5156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1720 AVIATION BLVD
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-2810
Practice Address - Country:US
Practice Address - Phone:310-376-4460
Practice Address - Fax:310-379-2136
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist