Provider Demographics
NPI:1912412628
Name:GROTEWIEL, SHASTA (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHASTA
Middle Name:
Last Name:GROTEWIEL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5329 DEEP BLUE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-2647
Mailing Address - Country:US
Mailing Address - Phone:919-903-5780
Mailing Address - Fax:
Practice Address - Street 1:7250 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4625
Practice Address - Country:US
Practice Address - Phone:843-572-8918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist