Provider Demographics
NPI:1871330860
Name:DICKEN, SHANNON OLIVIA (PHARMD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:OLIVIA
Last Name:DICKEN
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 1:2515 N WAUWATOSA AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1108
Mailing Address - Country:US
Mailing Address - Phone:480-299-4903
Mailing Address - Fax:
Practice Address - Street 1:900 N 92ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1202
Practice Address - Country:US
Practice Address - Phone:414-805-5117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22610-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist