Healthcare Provider Details

I. General information

NPI: 1801485073
Provider Name (Legal Business Name): HEATHER SHANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 W STATE ST
BOISE ID
83702-4039
US

IV. Provider business mailing address

11612 W ALFRED CT
BOISE ID
83713-1893
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-7684
  • Fax:
Mailing address:
  • Phone: 208-850-9116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP9131
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: