Provider Demographics
NPI:1356623813
Name:WALTSGOTT, SHANNON LEA (RPH)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEA
Last Name:WALTSGOTT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-4859
Mailing Address - Country:US
Mailing Address - Phone:618-416-1091
Mailing Address - Fax:314-382-1278
Practice Address - Street 1:7199 NATURAL BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-5143
Practice Address - Country:US
Practice Address - Phone:314-382-9926
Practice Address - Fax:314-382-1278
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003020549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist