Provider Demographics
NPI:1902124407
Name:MAISANO, SHANNON LEIGH (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEIGH
Last Name:MAISANO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15972 MYRTLE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-2208
Mailing Address - Country:US
Mailing Address - Phone:586-781-6045
Mailing Address - Fax:
Practice Address - Street 1:63303 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48095-2574
Practice Address - Country:US
Practice Address - Phone:586-781-8905
Practice Address - Fax:589-781-8971
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist