Provider Demographics
NPI:1285954750
Name:SHELTON, KEITH ALAN (RPH)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:SHELTON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-4856
Mailing Address - Country:US
Mailing Address - Phone:573-686-7216
Mailing Address - Fax:573-686-7217
Practice Address - Street 1:200 N 10TH ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4856
Practice Address - Country:US
Practice Address - Phone:573-686-7216
Practice Address - Fax:573-686-7217
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029271183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist