Provider Demographics
NPI:1376744243
Name:THOMAS, SHANNON L
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:L
Last Name:THOMAS
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 1:17205 BLACK CREEK CT
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:IN
Mailing Address - Zip Code:46743-9773
Mailing Address - Country:US
Mailing Address - Phone:260-657-1382
Mailing Address - Fax:
Practice Address - Street 1:2520 EAST DUPONT RD.
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:260-416-3140
Practice Address - Fax:260-416-3349
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020557A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist