Provider Demographics
NPI:1083992440
Name:BRADSTREET, SHANNON MICHAELA (CPHT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHAELA
Last Name:BRADSTREET
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15167 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3847
Mailing Address - Country:US
Mailing Address - Phone:402-896-2798
Mailing Address - Fax:
Practice Address - Street 1:13660 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-5233
Practice Address - Country:US
Practice Address - Phone:800-546-5677
Practice Address - Fax:866-632-7946
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician