Provider Demographics
NPI:1144994088
Name:GRUCELLA, SHAWN LEE (CPHT)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:LEE
Last Name:GRUCELLA
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11652 PHEASANT DR SW
Mailing Address - Street 2:
Mailing Address - City:FIFE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49633-9055
Mailing Address - Country:US
Mailing Address - Phone:609-744-6425
Mailing Address - Fax:
Practice Address - Street 1:902 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-8061
Practice Address - Country:US
Practice Address - Phone:231-258-2081
Practice Address - Fax:231-258-5883
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303028132183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5303028132OtherSTATE CERTIFICATION NUMBER