Provider Demographics
NPI:1760087738
Name:WILLIAMS, KEONJALA SHANAE (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:KEONJALA
Middle Name:SHANAE
Last Name:WILLIAMS
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 1:100 2ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:FL
Mailing Address - Zip Code:32052-6114
Mailing Address - Country:US
Mailing Address - Phone:386-792-2551
Mailing Address - Fax:386-792-3577
Practice Address - Street 1:100 2ND AVE SE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052-6114
Practice Address - Country:US
Practice Address - Phone:386-792-2551
Practice Address - Fax:386-792-3577
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS56665183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS56665OtherFLORIDA BOARD OF PHARMACY