MEDICARE: MR. PATRICK DEWAYNE SHANNON

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	26018335A	IN

General Provider Information

NPI Number	:	1396028171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PATRICK DEWAYNE SHANNON

Provider Business Mailing Address
First Line	:	6219 WILMARBEE DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-1543
Country	:	US
Telephone Number	:	260-433-5409
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 E CREIGHTON AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46803-3344
Country	:	US
Telephone Number	:	260-456-1841
Fax Number	:

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

Provider Enumeration Date	:	09/27/2011
Last Update Date	:	09/27/2011

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