Provider Demographics
NPI:1215214945
Name:VILLANUEVA, SHANNON SHALVIS
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:SHALVIS
Last Name:VILLANUEVA
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 1:3855 N HOYNE AVE
Mailing Address - Street 2:# 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3907
Mailing Address - Country:US
Mailing Address - Phone:312-369-9996
Mailing Address - Fax:
Practice Address - Street 1:1601 N WELLS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6001
Practice Address - Country:US
Practice Address - Phone:312-642-4008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051290493183500000X
NC14504183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist