Healthcare Provider Details

I. General information

NPI: 1891281853
Provider Name (Legal Business Name): SHANNON JAMES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

10800 COMANCHE RD NE APT 212
ALBUQUERQUE NM
87111-3967
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-105735
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: