=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407508765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMACY OF SHANNON HILLS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2022
-----------------------------------------------------
Last Update Date | 05/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13907 HIGH RD
-----------------------------------------------------
City | MABELVALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72103-3212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-451-7715
-----------------------------------------------------
Fax | 501-451-7761
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13907 HIGH RD
-----------------------------------------------------
City | MABELVALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72103-3212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-451-7715
-----------------------------------------------------
Fax | 501-451-7761
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHARMACIST IN CHARGE
-----------------------------------------------------
Name | CALLIE BENCH
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 501-451-7715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------