Provider Demographics
NPI:1902219421
Name:ROTH, SHANNON (PHARM D)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MILLERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17061-1334
Mailing Address - Country:US
Mailing Address - Phone:717-692-2161
Mailing Address - Fax:
Practice Address - Street 1:242 MARKET ST
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17061-1334
Practice Address - Country:US
Practice Address - Phone:717-692-2161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP444757183500000X
PARPI002432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist