Provider Demographics
NPI:1043825995
Name:WELCH, SHAAN NOONAN NOVAK
Entity Type:Individual
Prefix:
First Name:SHAAN
Middle Name:NOONAN NOVAK
Last Name:WELCH
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 1:305 LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-1481
Mailing Address - Country:US
Mailing Address - Phone:903-736-3678
Mailing Address - Fax:
Practice Address - Street 1:1800 S HIGH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75602-3210
Practice Address - Country:US
Practice Address - Phone:903-234-2785
Practice Address - Fax:903-234-2789
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist