Healthcare Provider Details

I. General information

NPI: 1225596620
Provider Name (Legal Business Name): JACOB SHELTON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 N MAIN ST
LORETTO TN
38469-2351
US

IV. Provider business mailing address

534 N MILITARY ST
LORETTO TN
38469-2327
US

V. Phone/Fax

Practice location:
  • Phone: 931-853-7421
  • Fax: 931-853-7451
Mailing address:
  • Phone: 931-853-7421
  • Fax: 931-853-7451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number41324
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: