Provider Demographics
NPI:1790397602
Name:SALAZAR, SHANELLE RODRIGUEZ
Entity type:Individual
Prefix:
First Name:SHANELLE
Middle Name:RODRIGUEZ
Last Name:SALAZAR
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 1:680 S BERENDO ST APT 325
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-1793
Mailing Address - Country:US
Mailing Address - Phone:619-746-0495
Mailing Address - Fax:
Practice Address - Street 1:200 W CENTER STREET PROMENADE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3960
Practice Address - Country:US
Practice Address - Phone:714-618-9540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89814183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist