Provider Demographics
NPI:1043953953
Name:DIAL, SHELBY LYNN (PHARMD, BCPS)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LYNN
Last Name:DIAL
Suffix:
Gender:F
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:LYNN
Other - Last Name:KINCAID
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD, BCPS
Mailing Address - Street 1:5263 RIVER VIEW RD
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:IL
Mailing Address - Zip Code:62561-9547
Mailing Address - Country:US
Mailing Address - Phone:217-416-4640
Mailing Address - Fax:
Practice Address - Street 1:2115 S MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4501
Practice Address - Country:US
Practice Address - Phone:217-726-1003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051303111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist