Provider Demographics
NPI:1932223906
Name:MAHAN, SHAWN ROBERT
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:ROBERT
Last Name:MAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 PROSPECT MILL DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-2694
Mailing Address - Country:US
Mailing Address - Phone:770-339-9194
Mailing Address - Fax:678-377-9093
Practice Address - Street 1:2925 BROWNS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-5505
Practice Address - Country:US
Practice Address - Phone:770-532-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH019549183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist