Provider Demographics
NPI:1467926360
Name:MCSHANE, PHILIP ALBERT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ALBERT
Last Name:MCSHANE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12345 VIDALIA RD
Mailing Address - Street 2:
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571-8309
Mailing Address - Country:US
Mailing Address - Phone:228-255-7800
Mailing Address - Fax:228-255-9999
Practice Address - Street 1:12345 VIDALIA RD
Practice Address - Street 2:
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571-8309
Practice Address - Country:US
Practice Address - Phone:228-255-7800
Practice Address - Fax:228-255-9999
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-09484183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist