Provider Demographics
NPI:1871278861
Name:HENDERSON, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 BRENTMOOR DR UNIT 1120
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4601
Mailing Address - Country:US
Mailing Address - Phone:276-229-6175
Mailing Address - Fax:
Practice Address - Street 1:1110 DICK POND RD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-5503
Practice Address - Country:US
Practice Address - Phone:843-232-0091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43919183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist