Provider Demographics
NPI:1023393550
Name:FRIEDEN, SHANNON SUE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SUE
Last Name:FRIEDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7919 W 1400 N
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-8335
Mailing Address - Country:US
Mailing Address - Phone:219-987-5202
Mailing Address - Fax:
Practice Address - Street 1:226 N HALLECK ST
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-8633
Practice Address - Country:US
Practice Address - Phone:219-987-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-16
Last Update Date:2011-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019292A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist