Provider Demographics
NPI:1245368182
Name:MCDANIEL, SHANNON WAYNE (RPH)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:WAYNE
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16554 JEFFERSON OAKS DR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4173
Mailing Address - Country:US
Mailing Address - Phone:225-673-6839
Mailing Address - Fax:
Practice Address - Street 1:17682 AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3304
Practice Address - Country:US
Practice Address - Phone:225-677-9503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15712183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist