Provider Demographics
NPI:1083205652
Name:NELSON-BRYANT, SHANNON BETH (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:BETH
Last Name:NELSON-BRYANT
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:BETH
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:31835 STATE HIGHWAY 25
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:MO
Mailing Address - Zip Code:63730-8364
Mailing Address - Country:US
Mailing Address - Phone:573-270-7671
Mailing Address - Fax:
Practice Address - Street 1:125 W KARSCH BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-2156
Practice Address - Country:US
Practice Address - Phone:573-756-5425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044986183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO044986OtherMISSOURI BOARD OF PHARMCY