Provider Demographics
NPI:1144609421
Name:SHULL, MARY (OPTICIAN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SHULL
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
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Mailing Address - Street 1:111 N HIGGINS AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802
Mailing Address - Country:US
Mailing Address - Phone:406-327-9988
Mailing Address - Fax:406-541-9981
Practice Address - Street 1:111 N HIGGINS AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4437
Practice Address - Country:US
Practice Address - Phone:406-327-9988
Practice Address - Fax:406-541-9981
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MTBL01-556156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician