Provider Demographics
NPI:1245325091
Name:CARLSON, SHANNON L (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:L
Last Name:CARLSON
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 1:6510 STAPLE RD
Mailing Address - Street 2:
Mailing Address - City:TWIN LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49457-8522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 RUDDIMAN DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-3148
Practice Address - Country:US
Practice Address - Phone:231-744-4718
Practice Address - Fax:231-744-5574
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist