MEDICARE: SHADY EBBO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	91994	CA

General Provider Information

NPI Number	:	1740136936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHADY EBBO

Provider Business Mailing Address
First Line	:	5623 KANAN RD
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-3358
Country	:	US
Telephone Number	:	818-991-5522
Fax Number	:

Provider Business Practice Location Address
First Line	:	5623 KANAN RD
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-3358
Country	:	US
Telephone Number	:	818-991-5522
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2026
Last Update Date	:	03/09/2026

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Directions to “ SHADY EBBO ” Practice Location

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