Provider Demographics
NPI:1487308573
Name:TIEU, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:TIEU
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 1:8629 120TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-5822
Mailing Address - Country:US
Mailing Address - Phone:425-822-0414
Mailing Address - Fax:
Practice Address - Street 1:8629 120TH AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-5822
Practice Address - Country:US
Practice Address - Phone:425-822-0414
Practice Address - Fax:425-822-0811
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61187114183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist