Provider Demographics
NPI:1558655845
Name:WYGONIK, SHANNON BETH (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:BETH
Last Name:WYGONIK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4567 RIVER CITY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-7411
Mailing Address - Country:US
Mailing Address - Phone:904-596-0021
Mailing Address - Fax:904-596-0021
Practice Address - Street 1:4567 RIVER CITY DR
Practice Address - Street 2:T-1974
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-7411
Practice Address - Country:US
Practice Address - Phone:904-596-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS44633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist