Provider Demographics
NPI:1740657519
Name:YALDO, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:YALDO
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 1:4132 CROOKS ST
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-1225
Mailing Address - Country:US
Mailing Address - Phone:248-935-1772
Mailing Address - Fax:
Practice Address - Street 1:6427 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2333
Practice Address - Country:US
Practice Address - Phone:248-626-3400
Practice Address - Fax:248-865-7784
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040914183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist