Provider Demographics
NPI:1275953507
Name:VAUGHAN, SHANNA (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:VAUGHAN
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 1:30 NIGHTINGALE RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CA
Mailing Address - Zip Code:93524-1730
Mailing Address - Country:US
Mailing Address - Phone:661-277-2052
Mailing Address - Fax:
Practice Address - Street 1:149 HART ST
Practice Address - Street 2:
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3430
Practice Address - Country:US
Practice Address - Phone:940-676-6310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-25
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist