Provider Demographics
NPI:1598368706
Name:SHANAHAN, KELLY K (RPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:SHANAHAN
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 1:8301 PROFESSIONAL PL
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-2237
Mailing Address - Country:US
Mailing Address - Phone:240-461-2982
Mailing Address - Fax:
Practice Address - Street 1:8301 PROFESSIONAL PL
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-2237
Practice Address - Country:US
Practice Address - Phone:240-461-2982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11738183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist