Provider Demographics
NPI:1457688764
Name:ROGERS, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROGERS
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 1:4500 N TARRANT PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4924
Mailing Address - Country:US
Mailing Address - Phone:817-485-2547
Mailing Address - Fax:
Practice Address - Street 1:4500 N TARRANT PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-4924
Practice Address - Country:US
Practice Address - Phone:817-485-2547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44771183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist