Provider Demographics
NPI:1861773335
Name:SMITH, SHANNON TODD (DPH)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:TODD
Last Name:SMITH
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 REDBUD RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-8765
Mailing Address - Country:US
Mailing Address - Phone:405-388-5701
Mailing Address - Fax:405-273-0542
Practice Address - Street 1:1427 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-5245
Practice Address - Country:US
Practice Address - Phone:405-273-8520
Practice Address - Fax:405-273-0542
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist