Provider Demographics
NPI:1841304441
Name:WELCH, SHANNON TATE (RPH)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:TATE
Last Name:WELCH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20995 CO. RD.3600
Mailing Address - Street 2:
Mailing Address - City:ST. JAMES
Mailing Address - State:MO
Mailing Address - Zip Code:65559
Mailing Address - Country:US
Mailing Address - Phone:573-265-0102
Mailing Address - Fax:
Practice Address - Street 1:1113 HAUCK DR
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2565
Practice Address - Country:US
Practice Address - Phone:573-364-9616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist