Provider Demographics
NPI:1265779102
Name:MOORE, SHANNON RENEE
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RENEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:MEEMKEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SHANNON KNIGHT
Mailing Address - Street 1:3330 INNER PERIMETER RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-671-9840
Mailing Address - Fax:229-269-4422
Practice Address - Street 1:13775 US 19 S
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5398
Practice Address - Country:US
Practice Address - Phone:229-228-6419
Practice Address - Fax:229-269-4422
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH020367183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist