MEDICARE: DR. JACKSON LANE SHANNON PHARM. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	45317	TN

General Provider Information

NPI Number	:	1285307835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACKSON LANE SHANNON PHARM. D.

Provider Business Mailing Address
First Line	:	17200 BRIDGETON LN
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-4808
Country	:	US
Telephone Number	:	423-415-2472
Fax Number	:

Provider Business Practice Location Address
First Line	:	8322 PINEVILLE MATTHEWS RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-4707
Country	:	US
Telephone Number	:	704-496-5228
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2021
Last Update Date	:	10/12/2024

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