Provider Demographics
NPI:1053784405
Name:STARWALT, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:STARWALT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24199 FINCH LN
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-9656
Mailing Address - Country:US
Mailing Address - Phone:541-929-2880
Mailing Address - Fax:541-929-2890
Practice Address - Street 1:1640 MAIN ST
Practice Address - Street 2:
Practice Address - City:PHILOMATH
Practice Address - State:OR
Practice Address - Zip Code:97370-9237
Practice Address - Country:US
Practice Address - Phone:541-929-2880
Practice Address - Fax:541-929-2890
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11120183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist