Basic Information
| Provider Information | |||||||||
| NPI: | 1366067308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIMADA | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMACIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4118 PINE BLOSSOM TRL | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770593225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818241480 | ||||||||
| FaxNumber: | 2812206407 | ||||||||
| Practice Location | |||||||||
| Address1: | 4118 PINE BLOSSOM TRL | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770593225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818241480 | ||||||||
| FaxNumber: | 2812206407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2020 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 38913 | TX | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 38913 | 01 | TX | TEXAS STATE BOARD OF EXAMINERS | OTHER |