Provider Demographics
NPI:1982105102
Name:SHUTTER, KIRSTIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KIRSTIE
Middle Name:
Last Name:SHUTTER
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 1:210 EMILY DR SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-5279
Mailing Address - Country:US
Mailing Address - Phone:770-609-6212
Mailing Address - Fax:
Practice Address - Street 1:6055 HIGHWAY 124 W
Practice Address - Street 2:
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548-5535
Practice Address - Country:US
Practice Address - Phone:706-654-5775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH028624183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1982105102Medicaid