Provider Demographics
NPI:1225311558
Name:BROWN, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 HERRINGTON RD
Mailing Address - Street 2:APT 10201
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-2280
Mailing Address - Country:US
Mailing Address - Phone:504-669-6029
Mailing Address - Fax:
Practice Address - Street 1:4765 REDAN RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-4550
Practice Address - Country:US
Practice Address - Phone:404-299-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022863183500000X
LA16525183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist