Provider Demographics
NPI:1245515733
Name:SHAPIRO, MARK ELLIS (RPH BSC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ELLIS
Last Name:SHAPIRO
Suffix:
Gender:M
Credentials:RPH BSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CENTERTON RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-6103
Mailing Address - Country:US
Mailing Address - Phone:856-359-3678
Mailing Address - Fax:856-359-5675
Practice Address - Street 1:100 ENTERTON RD
Practice Address - Street 2:COSTCO PHARMACY DEPT. 749
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-6103
Practice Address - Country:US
Practice Address - Phone:856-359-3678
Practice Address - Fax:856-359-3675
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01767000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI01767000OtherNEW JERSEY PHARMACIST LICENSE NUMBER