Provider Demographics
NPI:1780918342
Name:DAMMON, SHAIN JESSUP (PHARM D)
Entity type:Individual
Prefix:MR
First Name:SHAIN
Middle Name:JESSUP
Last Name:DAMMON
Suffix:
Gender:M
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 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:208-848-8290
Mailing Address - Fax:208-848-8291
Practice Address - Street 1:1203 IDAHO ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1940
Practice Address - Country:US
Practice Address - Phone:208-848-8290
Practice Address - Fax:208-848-8291
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5849183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6968OtherNONE
HI6968696869OtherNONE