Provider Demographics
NPI:1063822278
Name:SHELTON, RANDY (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:
Last Name:SHELTON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 S WEST AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6702
Mailing Address - Country:US
Mailing Address - Phone:815-297-0881
Mailing Address - Fax:815-297-0972
Practice Address - Street 1:1512 S WEST AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6702
Practice Address - Country:US
Practice Address - Phone:815-297-0881
Practice Address - Fax:815-297-0972
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051292414183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist