Provider Demographics
NPI:1275813107
Name:NELSON, SHAYVONE (PHARMD, PHD)
Entity Type:Individual
Prefix:
First Name:SHAYVONE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:PHARMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5595 WELLBORN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-3554
Mailing Address - Country:US
Mailing Address - Phone:856-392-6612
Mailing Address - Fax:
Practice Address - Street 1:5595 WELLBORN CREEK DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-3554
Practice Address - Country:US
Practice Address - Phone:856-392-6612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH025419183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist