Provider Demographics
NPI:1477677722
Name:SHANNON, MYCALE LLOYD (DROF PHARMACY)
Entity Type:Individual
Prefix:MR
First Name:MYCALE
Middle Name:LLOYD
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DROF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 QUAIL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-1320
Mailing Address - Country:US
Mailing Address - Phone:580-336-2136
Mailing Address - Fax:
Practice Address - Street 1:328 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-6607
Practice Address - Country:US
Practice Address - Phone:580-336-2136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3707188Medicare UPIN