Provider Demographics
NPI:1780338061
Name:WALDEN, SHANE PATRICK (PHARMD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:PATRICK
Last Name:WALDEN
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 1:109 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-3330
Mailing Address - Country:US
Mailing Address - Phone:620-365-3176
Mailing Address - Fax:
Practice Address - Street 1:109 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-3330
Practice Address - Country:US
Practice Address - Phone:620-365-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-103837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist