Provider Demographics
NPI:1780138131
Name:DETELICH, SHANNON (PHARMD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DETELICH
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 1:242 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-2931
Mailing Address - Country:US
Mailing Address - Phone:603-886-1786
Mailing Address - Fax:603-880-3937
Practice Address - Street 1:242 MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-2931
Practice Address - Country:US
Practice Address - Phone:603-886-1786
Practice Address - Fax:603-880-3937
Is Sole Proprietor?:No
Enumeration Date:2016-08-14
Last Update Date:2016-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3581183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist