Provider Demographics
NPI:1538495197
Name:MANN, SHELBY LEONA
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LEONA
Last Name:MANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:LEONA
Other - Last Name:ZWARYCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:208 CIBEQUE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550-0208
Mailing Address - Country:US
Mailing Address - Phone:928-475-7269
Mailing Address - Fax:
Practice Address - Street 1:208 CIBEQUE CIRCLE
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550-0208
Practice Address - Country:US
Practice Address - Phone:928-475-7269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5164183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist