Provider Demographics
NPI:1760523120
Name:FEDERICO, SHANNON (RPH)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FEDERICO
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 1:1502 STATE ROUTE 70
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:KY
Mailing Address - Zip Code:42064-7766
Mailing Address - Country:US
Mailing Address - Phone:270-965-3256
Mailing Address - Fax:
Practice Address - Street 1:119 EAST MAIN ST.
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:KY
Practice Address - Zip Code:42078
Practice Address - Country:US
Practice Address - Phone:270-988-3226
Practice Address - Fax:270-988-4357
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012629183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist