Healthcare Provider Details

I. General information

NPI: 1679829576
Provider Name (Legal Business Name): SHANNON MICHAEL PACE PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2012
Last Update Date: 07/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 S 5TH AVE
HINES IL
60141-3030
US

IV. Provider business mailing address

4560 N OPAL AVE
NORRIDGE IL
60706-4421
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-2488
  • Fax:
Mailing address:
  • Phone: 773-587-7054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051295846
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: