Provider Demographics
NPI:1144996836
Name:MACKRELL, SHAUN
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:MACKRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ARCHBALD
Mailing Address - State:PA
Mailing Address - Zip Code:18403-1586
Mailing Address - Country:US
Mailing Address - Phone:570-267-6376
Mailing Address - Fax:
Practice Address - Street 1:1315 COLD SPRING RD
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-1113
Practice Address - Country:US
Practice Address - Phone:570-383-8731
Practice Address - Fax:570-383-8740
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP439360183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist