Provider Demographics
NPI:1952512196
Name:DEWITT, SHANNON M (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:M
Last Name:DEWITT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1400 WAYNEDALE DR
Mailing Address - Street 2:
Mailing Address - City:GARRETT
Mailing Address - State:IN
Mailing Address - Zip Code:46738-2073
Mailing Address - Country:US
Mailing Address - Phone:260-357-1731
Mailing Address - Fax:
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:PHARMACY-SECOND FLOOR
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7702
Practice Address - Fax:260-435-6869
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019698A183500000X
OH03-2-23033183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist