Provider Demographics
NPI:1447850086
Name:SHAW, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
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:PO BOX 1412
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77864-1412
Mailing Address - Country:US
Mailing Address - Phone:936-348-4777
Mailing Address - Fax:
Practice Address - Street 1:2750 W UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-1628
Practice Address - Country:US
Practice Address - Phone:940-735-3126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30893183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist