Provider Demographics
NPI:1841671492
Name:RAYBURN, SHAWN DANELLE
Entity type:Individual
Prefix:MRS
First Name:SHAWN
Middle Name:DANELLE
Last Name:RAYBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7125 FM 559
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503
Mailing Address - Country:US
Mailing Address - Phone:903-276-5260
Mailing Address - Fax:870-898-5594
Practice Address - Street 1:1310 S CONSTITUTION AVE
Practice Address - Street 2:BROOKSHIRES PHARMACY 062
Practice Address - City:ASHDOWN
Practice Address - State:AR
Practice Address - Zip Code:71822
Practice Address - Country:US
Practice Address - Phone:903-276-5260
Practice Address - Fax:870-898-5594
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX31189183500000X
ARPD08930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPD08930OtherSTATE LICENSE
TXTX31189OtherSTATE LICENSE