Provider Demographics
NPI:1124672829
Name:SHAN, LEAH (PHARMD)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:SHAN
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 1:1820 GREGORY DR
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-3041
Mailing Address - Country:US
Mailing Address - Phone:618-919-1055
Mailing Address - Fax:
Practice Address - Street 1:515 BAYOU ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1034
Practice Address - Country:US
Practice Address - Phone:812-886-0907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.2960311835P0018X
IN26024929A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist