Provider Demographics
NPI:1356474332
Name:WIRTH, SHANNON LYN (RPH)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYN
Last Name:WIRTH
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 1:11711 WEST PRICE ROAD
Mailing Address - Street 2:
Mailing Address - City:WESTPHALIA
Mailing Address - State:MI
Mailing Address - Zip Code:48894
Mailing Address - Country:US
Mailing Address - Phone:989-224-6881
Mailing Address - Fax:989-227-3347
Practice Address - Street 1:901 S OAKLAND ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-2200
Practice Address - Country:US
Practice Address - Phone:989-224-6881
Practice Address - Fax:989-227-3347
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302030530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist