Provider Demographics
NPI:1932743077
Name:FAGAN, SHANE F
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:F
Last Name:FAGAN
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 1:915 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-1530
Mailing Address - Country:US
Mailing Address - Phone:724-812-2457
Mailing Address - Fax:
Practice Address - Street 1:1045 WHEELING AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-2441
Practice Address - Country:US
Practice Address - Phone:740-432-9301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03439246183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist