Healthcare Provider Details

I. General information

NPI: 1770984817
Provider Name (Legal Business Name): SHAWNA MARIE MIKKELSEN PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAWNA MARIE CORDON PHARMD

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S MAIN ST
MOSCOW ID
83843-3046
US

IV. Provider business mailing address

700 S MAIN ST
MOSCOW ID
83843-3046
US

V. Phone/Fax

Practice location:
  • Phone: 208-883-2236
  • Fax: 208-883-6550
Mailing address:
  • Phone: 208-883-2236
  • Fax: 208-883-6550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberRPH61612
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPH60232295
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPH60232295
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH61612
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: