Provider Demographics
NPI:1144336348
Name:ABBOTT, SHANE G (RPH)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:G
Last Name:ABBOTT
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 1:856 TEN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-4516
Mailing Address - Country:US
Mailing Address - Phone:850-859-9974
Mailing Address - Fax:
Practice Address - Street 1:1337 US HIGHWAY 90 W
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-1470
Practice Address - Country:US
Practice Address - Phone:850-892-6898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS-33343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist