Healthcare Provider Details

I. General information

NPI: 1831489830
Provider Name (Legal Business Name): SHAUN PETER MALLAM BPHARM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W LACEY BLVD
HANFORD CA
93230-4326
US

IV. Provider business mailing address

707 W LACEY BLVD
HANFORD CA
93230-4326
US

V. Phone/Fax

Practice location:
  • Phone: 559-584-1896
  • Fax: 559-584-4311
Mailing address:
  • Phone: 559-584-1896
  • Fax: 559-584-4311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number59280
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: