Provider Demographics
NPI:1114581733
Name:WATHEN, SHANNON (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WATHEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4334 S COLE CT
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:CO
Mailing Address - Zip Code:80465-1147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13420 W COAL MINE AVE
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80127-5402
Practice Address - Country:US
Practice Address - Phone:303-979-2870
Practice Address - Fax:303-979-5091
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21028OtherPHARMACY LICENSE