Provider Demographics
NPI:1235677170
Name:CARLISLE, SHANNON (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 MCLEAN CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7611
Mailing Address - Country:US
Mailing Address - Phone:217-433-2044
Mailing Address - Fax:
Practice Address - Street 1:2605 MCLEAN CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7611
Practice Address - Country:US
Practice Address - Phone:217-433-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014021073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist