Basic Information
Provider Information | |||||||||
NPI: | 1154667079 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PUCKETT MAY | ||||||||
FirstName: | SHANNON | ||||||||
MiddleName: | DIANNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARM.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PUCKETT | ||||||||
OtherFirstName: | SHANNON | ||||||||
OtherMiddleName: | DIANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHARM.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2713 STINSON PL | ||||||||
Address2: |   | ||||||||
City: | BILLINGS | ||||||||
State: | MT | ||||||||
PostalCode: | 591021344 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4064596559 | ||||||||
FaxNumber: | 4062385870 | ||||||||
Practice Location | |||||||||
Address1: | 123 S 27TH ST | ||||||||
Address2: |   | ||||||||
City: | BILLINGS | ||||||||
State: | MT | ||||||||
PostalCode: | 591014227 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4062473350 | ||||||||
FaxNumber: | 4062473389 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2012 | ||||||||
LastUpdateDate: | 05/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH60292584 | WA | N |   | Pharmacy Service Providers | Pharmacist |   | 1835P2201X | 11921 | MT | N |   |   |   |   | 1835P0018X | 11921 | MT | Y |   | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.