Provider Demographics
NPI:1942594296
Name:CORNELL, SHANNON LIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LIN
Last Name:CORNELL
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 1:10302 156TH ST E
Mailing Address - Street 2:PHARMACY DEPT
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-9321
Mailing Address - Country:US
Mailing Address - Phone:253-604-1067
Mailing Address - Fax:253-604-1077
Practice Address - Street 1:10302 156TH ST E
Practice Address - Street 2:PHARMACY DEPT
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-9321
Practice Address - Country:US
Practice Address - Phone:253-604-1067
Practice Address - Fax:253-604-1077
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00067684183500000X
SCPH10679183500000X
WVRP0006822W183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist