Provider Demographics
NPI:1316224017
Name:BLANKEN, SHANNON N (RPH)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:N
Last Name:BLANKEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-5127
Mailing Address - Country:US
Mailing Address - Phone:541-461-1433
Mailing Address - Fax:541-461-1443
Practice Address - Street 1:60 DIVISION AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-5127
Practice Address - Country:US
Practice Address - Phone:541-461-1433
Practice Address - Fax:541-461-1443
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11448183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR11448OtherRPH LICENSE