Provider Demographics
NPI:1497341259
Name:THOMPSON, SHANNON RAINES (RPH)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAINES
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:EAST BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36426-2620
Mailing Address - Country:US
Mailing Address - Phone:251-809-1010
Mailing Address - Fax:251-241-0020
Practice Address - Street 1:305 FORREST AVE
Practice Address - Street 2:
Practice Address - City:EAST BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-2620
Practice Address - Country:US
Practice Address - Phone:251-809-1010
Practice Address - Fax:251-241-0020
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018053183500000X
AL13515183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist