Healthcare Provider Details

I. General information

NPI: 1194717645
Provider Name (Legal Business Name): MARTHA JANE SHEPARD D.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7723 CLEARVIEW CHURCH LN
LYLES TN
37098-1609
US

IV. Provider business mailing address

204 MCCREARY HTS
DICKSON TN
37055-1217
US

V. Phone/Fax

Practice location:
  • Phone: 931-670-6035
  • Fax:
Mailing address:
  • Phone: 615-446-9782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number686
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: