Provider Demographics
NPI:1346869153
Name:BAILEY, SHANNON (RPH)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5308 W IRLO BRONSON MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746
Mailing Address - Country:US
Mailing Address - Phone:407-390-9431
Mailing Address - Fax:
Practice Address - Street 1:5308 W IRLO BRONSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-4754
Practice Address - Country:US
Practice Address - Phone:407-390-9431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-11
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS51953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist