Provider Demographics
NPI:1366711335
Name:VANVALKENBURG, SHAWN H
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:H
Last Name:VANVALKENBURG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 SEIBERLING DR
Mailing Address - Street 2:
Mailing Address - City:SAGAMORE HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44067-3240
Mailing Address - Country:US
Mailing Address - Phone:330-468-3941
Mailing Address - Fax:
Practice Address - Street 1:5400 PEARL RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-1545
Practice Address - Country:US
Practice Address - Phone:440-886-6198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03223503183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist