Provider Demographics
NPI:1679829576
Name:PACE, SHANNON MICHAEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MICHAEL
Last Name:PACE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 N OPAL AVE
Mailing Address - Street 2:
Mailing Address - City:NORRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60706-4421
Mailing Address - Country:US
Mailing Address - Phone:773-587-7054
Mailing Address - Fax:
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-2488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-28
Last Update Date:2012-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295846183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist