Provider Demographics
NPI:1649938192
Name:WALCZAK, SHAUNA JOY (PHARMD)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:JOY
Last Name:WALCZAK
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 1:11152 PUTNAM DR
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-0169
Mailing Address - Country:US
Mailing Address - Phone:219-614-0343
Mailing Address - Fax:
Practice Address - Street 1:225 JOLIET ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1709
Practice Address - Country:US
Practice Address - Phone:219-322-3014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029555A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist