Provider Demographics
NPI:1427523646
Name:SHELTON, KENNETH ROBERT (RPH)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
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 1:1123 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2692
Mailing Address - Country:US
Mailing Address - Phone:541-963-5741
Mailing Address - Fax:541-963-6332
Practice Address - Street 1:1123 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2692
Practice Address - Country:US
Practice Address - Phone:541-963-5741
Practice Address - Fax:541-963-6332
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6173183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist