Provider Demographics
NPI:1396028171
Name:SHANNON, PATRICK DEWAYNE
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:DEWAYNE
Last Name:SHANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6219 WILMARBEE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1543
Mailing Address - Country:US
Mailing Address - Phone:260-433-5409
Mailing Address - Fax:
Practice Address - Street 1:110 E CREIGHTON AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46803-3344
Practice Address - Country:US
Practice Address - Phone:260-456-1841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018335A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist