Healthcare Provider Details

I. General information

NPI: 1063338986
Provider Name (Legal Business Name): SHANNEL KWON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 HOWARD RD
MADERA CA
93637-5125
US

IV. Provider business mailing address

8072 N MILLBROOK AVE APT 107
FRESNO CA
93720-2290
US

V. Phone/Fax

Practice location:
  • Phone: 559-661-8380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number91827
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: