Provider Demographics
NPI:1497335079
Name:SHANAHAN, KIMBERLY (RPHT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:SHANAHAN
Suffix:
Gender:F
Credentials:RPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18140 SAN PEDRO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1421
Mailing Address - Country:US
Mailing Address - Phone:210-490-5593
Mailing Address - Fax:
Practice Address - Street 1:18140 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1421
Practice Address - Country:US
Practice Address - Phone:210-490-5593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200117061027851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist