Healthcare Provider Details

I. General information

NPI: 1811279508
Provider Name (Legal Business Name): SHANNON BUHMANN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2011
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6607 STATE ROUTE 162
MARYVILLE IL
62062-8514
US

IV. Provider business mailing address

9928 HOLY CROSS LN
BREESE IL
62230-3604
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-2130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.292248
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: