Provider Demographics
NPI:1659103026
Name:MARTIN, SHANNON (PHARMD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MARTIN
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 1:9240 EDGEMONT LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-5521
Mailing Address - Country:US
Mailing Address - Phone:786-277-5530
Mailing Address - Fax:
Practice Address - Street 1:3015 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2013
Practice Address - Country:US
Practice Address - Phone:954-475-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS67493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist