Provider Demographics
NPI:1174119077
Name:VAN DOREN, SHANNA (CPHT)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:VAN DOREN
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33443 SCARBOROUGH LN
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-5632
Mailing Address - Country:US
Mailing Address - Phone:760-594-1332
Mailing Address - Fax:401-652-1417
Practice Address - Street 1:29676 RANCHO CALIFORNIA RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5283
Practice Address - Country:US
Practice Address - Phone:951-693-2704
Practice Address - Fax:401-652-1417
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATCH30779183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician