Provider Demographics
NPI:1780705053
Name:NORRIS, SHANE WINSTON (PHARMD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:WINSTON
Last Name:NORRIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11819 W HAYWARD RD
Mailing Address - Street 2:
Mailing Address - City:DRUMMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73735-1098
Mailing Address - Country:US
Mailing Address - Phone:580-493-2947
Mailing Address - Fax:
Practice Address - Street 1:11819 W HAYWARD RD
Practice Address - Street 2:
Practice Address - City:DRUMMOND
Practice Address - State:OK
Practice Address - Zip Code:73735-1098
Practice Address - Country:US
Practice Address - Phone:580-493-2947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13364183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK13364OtherPHARMACIST LICENSE