Provider Demographics
NPI:1356664536
Name:PEDERSON, SHANNON GERALD (RPH)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:GERALD
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2903 NE ANDRESEN RD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7329
Mailing Address - Country:US
Mailing Address - Phone:360-256-1503
Mailing Address - Fax:
Practice Address - Street 1:2903 NE ANDRESSEN RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661
Practice Address - Country:US
Practice Address - Phone:360-256-1503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00017762183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist