Provider Demographics
NPI:1568065589
Name:ROESSLET, SHAWN
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:ROESSLET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18401 STATE HWY 13
Mailing Address - Street 2:
Mailing Address - City:BRANSON WEST
Mailing Address - State:MO
Mailing Address - Zip Code:65737
Mailing Address - Country:US
Mailing Address - Phone:417-343-5960
Mailing Address - Fax:
Practice Address - Street 1:18401 STATE HWY 13
Practice Address - Street 2:
Practice Address - City:BRANSON WEST
Practice Address - State:MO
Practice Address - Zip Code:65737
Practice Address - Country:US
Practice Address - Phone:417-343-5960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044743183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist