Provider Demographics
NPI:1104361344
Name:HALL, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HALL
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 1:38804 KINGSBURY RD
Mailing Address - Street 2:
Mailing Address - City:POMEROY
Mailing Address - State:OH
Mailing Address - Zip Code:45769-9689
Mailing Address - Country:US
Mailing Address - Phone:740-508-1272
Mailing Address - Fax:
Practice Address - Street 1:2501 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-2035
Practice Address - Country:US
Practice Address - Phone:304-675-2303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-26
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVTT0011066183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician