Provider Demographics
NPI:1386332534
Name:CLARKE - FORREST, SHANIQUE N
Entity type:Individual
Prefix:
First Name:SHANIQUE
Middle Name:N
Last Name:CLARKE - FORREST
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 1:11750 MOUNT VERNON AVE # O157
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-8202
Mailing Address - Country:US
Mailing Address - Phone:240-502-0840
Mailing Address - Fax:
Practice Address - Street 1:7170 DAY CREEK BLVD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-8821
Practice Address - Country:US
Practice Address - Phone:909-463-7846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87313183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist