Basic Information
| Provider Information | |||||||||
| NPI: | 1053706473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIN | ||||||||
| FirstName: | JI-YEON | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARM D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2588 STONE MANOR WAY | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370431517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314725295 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988074 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2015 | ||||||||
| LastUpdateDate: | 12/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 0202213174 | VA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.