Provider Demographics
NPI:1851691661
Name:SMITH, SHANNON L (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21274 N JOHN WAYNE PKWY
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139-8952
Mailing Address - Country:US
Mailing Address - Phone:520-568-0672
Mailing Address - Fax:
Practice Address - Street 1:21274 N JOHN WAYNE PKWY
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85139-8952
Practice Address - Country:US
Practice Address - Phone:520-568-0672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15534183500000X
WI14861-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist