Provider Demographics
NPI:1104912633
Name:THORNTON, SHANNON J (RPH)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:J
Last Name:THORNTON
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 1:4854 COUNTY RD 117A
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785
Mailing Address - Country:US
Mailing Address - Phone:352-748-1809
Mailing Address - Fax:
Practice Address - Street 1:3700 W. SOVEREIGN PATH
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461
Practice Address - Country:US
Practice Address - Phone:352-527-0068
Practice Address - Fax:352-527-3013
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11556183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11556OtherLICENSE NUMBER