Provider Demographics
NPI:1346535150
Name:CLARK, SHANNON WAYNE (RPH)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:WAYNE
Last Name:CLARK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2747 GULF TO BAY BLVD
Mailing Address - Street 2:T-1820
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3945
Mailing Address - Country:US
Mailing Address - Phone:727-431-0232
Mailing Address - Fax:
Practice Address - Street 1:2747 GULF TO BAY BLVD
Practice Address - Street 2:T-1820
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-3945
Practice Address - Country:US
Practice Address - Phone:727-431-0232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS14455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist