Provider Demographics
NPI:1134779879
Name:O'CONNOR, SHANE PATRICK (PHA)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:PATRICK
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:PHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 16TH ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-3205
Mailing Address - Country:US
Mailing Address - Phone:303-571-5314
Mailing Address - Fax:
Practice Address - Street 1:801 16TH ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-3205
Practice Address - Country:US
Practice Address - Phone:303-571-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-15
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0022895183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist