Provider Demographics
NPI:1831489830
Name:MALLAM, SHAUN PETER (BPHARM)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:PETER
Last Name:MALLAM
Suffix:
Gender:M
Credentials:BPHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 W LACEY BLVD
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-4326
Mailing Address - Country:US
Mailing Address - Phone:559-584-1896
Mailing Address - Fax:559-584-4311
Practice Address - Street 1:707 W LACEY BLVD
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-4326
Practice Address - Country:US
Practice Address - Phone:559-584-1896
Practice Address - Fax:559-584-4311
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59280183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist