Provider Demographics
NPI:1871620880
Name:SHANAHAN, ROBERTA L (PHARM D)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:L
Last Name:SHANAHAN
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 BENT WAY
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7614
Mailing Address - Country:US
Mailing Address - Phone:303-678-3243
Mailing Address - Fax:
Practice Address - Street 1:2345 BENT WAY
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-7614
Practice Address - Country:US
Practice Address - Phone:303-678-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15986208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
013254OtherKAISER-COMMERCIAL NUMBER