Healthcare Provider Details

I. General information

NPI: 1598165557
Provider Name (Legal Business Name): SHANNON NICOLE LEE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

884 RIVER RD
EUGENE OR
97404-3233
US

IV. Provider business mailing address

884 RIVER RD
EUGENE OR
97404-3233
US

V. Phone/Fax

Practice location:
  • Phone: 541-636-3522
  • Fax: 541-636-4069
Mailing address:
  • Phone: 541-636-3522
  • Fax: 541-636-4069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH0014172
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH0014172
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: