1114537701 NPI number — DR. SHANNON BROOKE VAN HORN PHARMD

Table of content: DR. SHANNON BROOKE VAN HORN PHARMD (NPI 1114537701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114537701 NPI number — DR. SHANNON BROOKE VAN HORN PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN HORN
Provider First Name:
SHANNON
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PROSSER
Provider Other First Name:
SHANNON
Provider Other Middle Name:
BROOKE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114537701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
157 CALIFORNIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK RIDGE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37830-4001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-360-6915
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
507 FOOTHILLS PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37801-2312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-238-7436
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  43596 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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