Provider Demographics
NPI:1972136273
Name:SULIK, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SULIK
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 1:774 HIGHWAY 96
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3300
Mailing Address - Country:US
Mailing Address - Phone:478-988-5710
Mailing Address - Fax:478-988-5720
Practice Address - Street 1:774 HIGHWAY 96
Practice Address - Street 2:
Practice Address - City:BONAIRE
Practice Address - State:GA
Practice Address - Zip Code:31005-3300
Practice Address - Country:US
Practice Address - Phone:478-988-5710
Practice Address - Fax:478-988-5720
Is Sole Proprietor?:No
Enumeration Date:2020-02-15
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0274741835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist