Provider Demographics
NPI:1336749688
Name:SHEPHERD, WADE D (PHARMD)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:D
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 W HEMPHILL DR
Mailing Address - Street 2:
Mailing Address - City:NINEVEH
Mailing Address - State:IN
Mailing Address - Zip Code:46164-8915
Mailing Address - Country:US
Mailing Address - Phone:812-350-8168
Mailing Address - Fax:
Practice Address - Street 1:2715 MERCHANT MILE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-1573
Practice Address - Country:US
Practice Address - Phone:812-373-9273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024233A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist