Provider Demographics
NPI:1285307835
Name:SHANNON, JACKSON LANE (PHARM D)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:LANE
Last Name:SHANNON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17200 BRIDGETON LN
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-4808
Mailing Address - Country:US
Mailing Address - Phone:423-415-2472
Mailing Address - Fax:
Practice Address - Street 1:8322 PINEVILLE MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-4707
Practice Address - Country:US
Practice Address - Phone:704-496-5228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45317183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist