Provider Demographics
NPI:1962745299
Name:TAYLOR, SHAWN R
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:R
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 GOFF MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1410
Mailing Address - Country:US
Mailing Address - Phone:304-769-0590
Mailing Address - Fax:304-769-0596
Practice Address - Street 1:101 GOFF MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1410
Practice Address - Country:US
Practice Address - Phone:304-769-0590
Practice Address - Fax:304-769-0596
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist