Provider Demographics
NPI:1902277536
Name:AFSHAR, SHAH (RPH)
Entity Type:Individual
Prefix:
First Name:SHAH
Middle Name:
Last Name:AFSHAR
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4901
Mailing Address - Country:US
Mailing Address - Phone:208-939-8008
Mailing Address - Fax:208-938-1067
Practice Address - Street 1:149 W STATE ST
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4901
Practice Address - Country:US
Practice Address - Phone:208-939-8008
Practice Address - Fax:208-938-1067
Is Sole Proprietor?:No
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist