Provider Demographics
NPI:1154455673
Name:DUDLEY, SHANE A (RPH)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:A
Last Name:DUDLEY
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 1:410 WARD AVE
Mailing Address - Street 2:
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830-1451
Mailing Address - Country:US
Mailing Address - Phone:573-922-9199
Mailing Address - Fax:
Practice Address - Street 1:410 WARD AVE
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830-1451
Practice Address - Country:US
Practice Address - Phone:573-333-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO043832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600126106Medicaid
MO620126102Medicaid