Provider Demographics
NPI:1215512975
Name:KIM, SHANNON LEEANN (PHARMD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEEANN
Last Name:KIM
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 1:550 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-7028
Mailing Address - Country:US
Mailing Address - Phone:909-874-6700
Mailing Address - Fax:
Practice Address - Street 1:550 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-7028
Practice Address - Country:US
Practice Address - Phone:909-874-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-15
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84207183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist