=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396227880
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANE JOSEPH DAUGHERTY RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2018
-----------------------------------------------------
Last Update Date | 12/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 144 POST AVENUE
-----------------------------------------------------
City | NEW STANTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-925-9810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 515
-----------------------------------------------------
City | NEW STANTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15672-0515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-925-9810
-----------------------------------------------------
Fax | 724-925-1730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP452360
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------