Provider Demographics
NPI:1619560372
Name:MACK, SHUNDRA
Entity Type:Individual
Prefix:
First Name:SHUNDRA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 COUNTY ROAD 2781
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633-6194
Mailing Address - Country:US
Mailing Address - Phone:903-754-1623
Mailing Address - Fax:
Practice Address - Street 1:3301 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7959
Practice Address - Country:US
Practice Address - Phone:903-663-4362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-13
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64902183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist