Provider Demographics
NPI:1225674567
Name:HETLER, SHELLY R (RPH)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:R
Last Name:HETLER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14626 FLATROCK RD
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46773-9122
Mailing Address - Country:US
Mailing Address - Phone:260-580-5126
Mailing Address - Fax:
Practice Address - Street 1:5725 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7146
Practice Address - Country:US
Practice Address - Phone:260-432-2475
Practice Address - Fax:260-432-2494
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018797183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist