Provider Demographics
NPI:1598165763
Name:PUKL, SHANNON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:PUKL
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 1:110 BERLIN RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452-8366
Mailing Address - Country:US
Mailing Address - Phone:304-269-2443
Mailing Address - Fax:
Practice Address - Street 1:110 BERLIN RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-8366
Practice Address - Country:US
Practice Address - Phone:304-269-2443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0008144183500000X
PARP448359183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist