Provider Demographics
NPI:1215156716
Name:WOMACK, SHANNON RICHARD
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:RICHARD
Last Name:WOMACK
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 1:695 WATERFORD WAY
Mailing Address - Street 2:
Mailing Address - City:ASHFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36312-5457
Mailing Address - Country:US
Mailing Address - Phone:334-899-4449
Mailing Address - Fax:
Practice Address - Street 1:1151 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3021
Practice Address - Country:US
Practice Address - Phone:334-673-1804
Practice Address - Fax:334-673-1903
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS28780183500000X
AL13782183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist