Provider Demographics
NPI:1679286140
Name:KIMBALL, SHANNON KATHERINE (PHARMD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KATHERINE
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17900 NW ANASTASIA DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-8502
Mailing Address - Country:US
Mailing Address - Phone:503-621-8487
Mailing Address - Fax:
Practice Address - Street 1:364 SE 8TH AVE STE 107
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4243
Practice Address - Country:US
Practice Address - Phone:503-681-1338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-00191451835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care