Provider Demographics
NPI:1770984817
Name:MIKKELSEN, SHAWNA MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:SHAWNA
Middle Name:MARIE
Last Name:MIKKELSEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:SHAWNA
Other - Middle Name:MARIE
Other - Last Name:CORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3046
Mailing Address - Country:US
Mailing Address - Phone:208-883-2236
Mailing Address - Fax:208-883-6550
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3046
Practice Address - Country:US
Practice Address - Phone:208-883-2236
Practice Address - Fax:208-883-6550
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH602322951835P0018X, 1835P1200X
CARPH616121835P1200X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy