Provider Demographics
NPI:1386748333
Name:SHANNON PHARMACY
Entity type:Organization
Organization Name:SHANNON PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RATLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-295-4772
Mailing Address - Street 1:PO BOX 315
Mailing Address - Street 2:
Mailing Address - City:SHANNON
Mailing Address - State:GA
Mailing Address - Zip Code:30172-0315
Mailing Address - Country:US
Mailing Address - Phone:706-295-4772
Mailing Address - Fax:706-295-2866
Practice Address - Street 1:5855 NEW CALHOUN HWY NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-8253
Practice Address - Country:US
Practice Address - Phone:706-295-4772
Practice Address - Fax:706-295-2866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0088613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA779754709AMedicaid
2015642OtherPK
5235220001Medicare NSC