Healthcare Provider Details

I. General information

NPI: 1144996836
Provider Name (Legal Business Name): SHAUN MACKRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2021
Last Update Date: 08/21/2021
Certification Date: 08/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 COLD SPRING RD
SCRANTON PA
18508-1113
US

IV. Provider business mailing address

428 W CHURCH ST
ARCHBALD PA
18403-1586
US

V. Phone/Fax

Practice location:
  • Phone: 570-383-8731
  • Fax: 570-383-8740
Mailing address:
  • Phone: 570-267-6376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP439360
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: