Healthcare Provider Details

I. General information

NPI: 1689906893
Provider Name (Legal Business Name): SHANNON NICHOLS HOUSE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2010
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 MITT LARY RD
NORTHPORT AL
35475-4978
US

IV. Provider business mailing address

13832 GLENVIEW DR
NORTHPORT AL
35475-4976
US

V. Phone/Fax

Practice location:
  • Phone: 205-409-9777
  • Fax: 205-409-9778
Mailing address:
  • Phone: 205-409-9777
  • Fax: 205-409-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12934
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: