Provider Demographics
NPI:1154509420
Name:SHIPE, STUART S (RPH, DOM)
Entity type:Individual
Prefix:
First Name:STUART
Middle Name:S
Last Name:SHIPE
Suffix:
Gender:M
Credentials:RPH, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 PROMENADE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-8909
Mailing Address - Country:US
Mailing Address - Phone:772-467-2003
Mailing Address - Fax:
Practice Address - Street 1:1801 SE HILLMOOR DR
Practice Address - Street 2:SUITE A104
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7553
Practice Address - Country:US
Practice Address - Phone:772-398-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22540183500000X
FLAP1627171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No183500000XPharmacy Service ProvidersPharmacist