Provider Demographics
NPI:1043703952
Name:BALZAMO, SHANNA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNA
Middle Name:
Last Name:BALZAMO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:SHANNA
Other - Middle Name:
Other - Last Name:BURNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:5331 VERNON TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:FL
Mailing Address - Zip Code:32531-8453
Mailing Address - Country:US
Mailing Address - Phone:205-789-1652
Mailing Address - Fax:
Practice Address - Street 1:917 MAR WALT DR STE C
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6651
Practice Address - Country:US
Practice Address - Phone:850-312-3570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS48358183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist