Provider Demographics
NPI:1477190114
Name:CANZONERI, SHANNON VALLEE (PHARM D)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:VALLEE
Last Name:CANZONERI
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:SUSAN
Other - Last Name:VALLEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:4500 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2515
Mailing Address - Country:US
Mailing Address - Phone:228-865-3525
Mailing Address - Fax:228-865-3618
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:228-865-3525
Practice Address - Fax:228-865-3618
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-010116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist