Healthcare Provider Details

I. General information

NPI: 1750291662
Provider Name (Legal Business Name): JONATHAN MCSHANE CLINICAL PHARMACIST
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FISHER ST
BILOXI MS
39534-2508
US

IV. Provider business mailing address

14296 SAYBROOK PL
GULFPORT MS
39503-4133
US

V. Phone/Fax

Practice location:
  • Phone: 228-377-9240
  • Fax:
Mailing address:
  • Phone: 228-563-4937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberE-13107
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: