Provider Demographics
NPI:1417410309
Name:HANCOCK, SHANE EDWIN (PHARMD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:EDWIN
Last Name:HANCOCK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3895 HARRISON BLVD
Mailing Address - Street 2:C/O MCKAY-DEE NORTH CAMPUS PHARMACY
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2312
Mailing Address - Country:US
Mailing Address - Phone:801-387-8550
Mailing Address - Fax:801-387-8557
Practice Address - Street 1:3895 HARRISON BLVD
Practice Address - Street 2:C/O 1ST FLOOR PHARMACY
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-8440
Practice Address - Country:US
Practice Address - Phone:801-387-8550
Practice Address - Fax:801-387-8555
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7325645-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7325645-8911OtherUTAH STATE PHARMACIST CONTROLLED SUBSTANCES LICENSE
UT7325645-1701OtherUTAH STATE PHARMACIST LICENSE