Healthcare Provider Details

I. General information

NPI: 1790052157
Provider Name (Legal Business Name): SHELLNUTS ACES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 BRADFORD HICKS DR STE B
LIVINGSTON TN
38570-2247
US

IV. Provider business mailing address

PO BOX 375
LIVINGSTON TN
38570-0375
US

V. Phone/Fax

Practice location:
  • Phone: 931-403-2552
  • Fax: 931-403-2556
Mailing address:
  • Phone: 931-403-2552
  • Fax: 931-403-2556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number4949
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN MELTON
Title or Position: PHARMACIST
Credential:
Phone: 931-261-6332