Provider Demographics
NPI:1679174643
Name:BERRY, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BERRY
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 1:104 FREDERICK LN
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-9738
Mailing Address - Country:US
Mailing Address - Phone:816-914-7533
Mailing Address - Fax:
Practice Address - Street 1:1307 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-5109
Practice Address - Country:US
Practice Address - Phone:816-318-0404
Practice Address - Fax:816-318-0446
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015025621183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist