MEDICARE: DR. SHANNON BETH WYGONIK PHARMD

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	PS44633	FL

General Provider Information

NPI Number	:	1558655845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON BETH WYGONIK PHARMD

Provider Business Mailing Address
First Line	:	4567 RIVER CITY DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-7411
Country	:	US
Telephone Number	:	904-596-0021
Fax Number	:	904-596-0021

Provider Business Practice Location Address
First Line	:	4567 RIVER CITY DR
Second Line	:	T-1974
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-7411
Country	:	US
Telephone Number	:	904-596-0021
Fax Number	:

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

Provider Enumeration Date	:	06/03/2011
Last Update Date	:	06/03/2011

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