Healthcare Provider Details

I. General information

NPI: 1942433024
Provider Name (Legal Business Name): SHANNON DYKE PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 05/04/2025
Certification Date: 05/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 BECKNER RD
SANTA FE NM
87507-3641
US

IV. Provider business mailing address

4605 CROYDEN AVE NW
ALBUQUERQUE NM
87114-4243
US

V. Phone/Fax

Practice location:
  • Phone: 505-772-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00006873
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPC147
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: