Provider Demographics
NPI:1023100419
Name:SHEA, MICHAEL SHANNON (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SHANNON
Last Name:SHEA
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 1:9226 STADIUM DRIVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009
Mailing Address - Country:US
Mailing Address - Phone:269-372-7147
Mailing Address - Fax:
Practice Address - Street 1:300 RENO DR
Practice Address - Street 2:WAYLAND VILLAGE PHARMACY
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348
Practice Address - Country:US
Practice Address - Phone:269-792-6223
Practice Address - Fax:269-792-6349
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist