Healthcare Provider Details

I. General information

NPI: 1568694297
Provider Name (Legal Business Name): SHELBINA PHARMACY L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N CENTER ST STE A
SHELBINA MO
63468-1117
US

IV. Provider business mailing address

201 N CENTER ST STE A
SHELBINA MO
63468-1117
US

V. Phone/Fax

Practice location:
  • Phone: 573-588-2143
  • Fax: 573-588-7545
Mailing address:
  • Phone: 573-588-2143
  • Fax: 573-588-7545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2015016416
License Number StateMO

VIII. Authorized Official

Name: JONATHAN PATRICK EARLEY
Title or Position: OWNER/PIC
Credential:
Phone: 573-588-2143