Provider Demographics
NPI:1336806033
Name:SHEPHERD, HAYLEY BROOKE
Entity type:Individual
Prefix:
First Name:HAYLEY
Middle Name:BROOKE
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WILLIAMTON GROVE DR
Mailing Address - Street 2:
Mailing Address - City:ELKVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:25071-7422
Mailing Address - Country:US
Mailing Address - Phone:304-545-9782
Mailing Address - Fax:
Practice Address - Street 1:8 ELK PLZ
Practice Address - Street 2:
Practice Address - City:ELKVIEW
Practice Address - State:WV
Practice Address - Zip Code:25071-9602
Practice Address - Country:US
Practice Address - Phone:304-965-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202220094183500000X
WVRP0012712183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist