Provider Demographics
NPI:1437742384
Name:CADDELL, SHANNON WAYNE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:WAYNE
Last Name:CADDELL
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 1:805 N WHITTINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-7101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 PRIVATE ROAD 3454
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:TX
Practice Address - Zip Code:76073-2447
Practice Address - Country:US
Practice Address - Phone:682-225-1975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX372471835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric