Provider Demographics
NPI:1992099329
Name:BENNER, SHANNON JO (PHARMD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:JO
Last Name:BENNER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 TOWNE CENTER DR
Mailing Address - Street 2:T-1071
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-4146
Mailing Address - Country:US
Mailing Address - Phone:502-412-2440
Mailing Address - Fax:502-412-2440
Practice Address - Street 1:4101 TOWNE CENTER DR
Practice Address - Street 2:T-1071
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-4146
Practice Address - Country:US
Practice Address - Phone:502-412-2440
Practice Address - Fax:502-412-2440
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY013785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist