Provider Demographics
NPI:1164824272
Name:MCMILLAN, SHANE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2603
Mailing Address - Country:US
Mailing Address - Phone:660-582-2199
Mailing Address - Fax:660-582-2456
Practice Address - Street 1:1217 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2603
Practice Address - Country:US
Practice Address - Phone:660-582-2199
Practice Address - Fax:660-582-2456
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011027356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist