Basic Information
| Provider Information | |||||||||
| NPI: | 1851617773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHRIVER | ||||||||
| FirstName: | SHANI | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BJERKE | ||||||||
| OtherFirstName: | SHANI | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24760 HOSPTIAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186793912 | ||||||||
| FaxNumber: | 2186790189 | ||||||||
| Practice Location | |||||||||
| Address1: | 24760 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186793912 | ||||||||
| FaxNumber: | 2186790189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2010 | ||||||||
| LastUpdateDate: | 05/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | 119806 | MN | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
ID Information
| ID | Type | State | Issuer | Description | 119806 | 01 | MN | PHARMACIST LICENSE | OTHER |