Provider Demographics
NPI:1992551220
Name:STITTSWORTH, SHANNON (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:STITTSWORTH
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 1:212 W SAINT CHARLES RD APT 403
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-2273
Mailing Address - Country:US
Mailing Address - Phone:904-483-1938
Mailing Address - Fax:
Practice Address - Street 1:212 W SAINT CHARLES RD APT 403
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-2273
Practice Address - Country:US
Practice Address - Phone:904-483-1938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051304072183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist