Provider Demographics
NPI:1023424082
Name:GERWIEN, SHANNON
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:GERWIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 PORTSMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:NH
Mailing Address - Zip Code:03833-2124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2505 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3019
Practice Address - Country:US
Practice Address - Phone:203-288-5217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0012960183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist