Provider Demographics
NPI:1316379670
Name:SHULUSKY, STEPHEN RANDALL (PHARMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RANDALL
Last Name:SHULUSKY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 BELLEVIEW AVE
Mailing Address - Street 2:APT #2
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-3300
Mailing Address - Country:US
Mailing Address - Phone:303-229-2228
Mailing Address - Fax:
Practice Address - Street 1:315 W 2ND ST
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-1419
Practice Address - Country:US
Practice Address - Phone:719-384-6616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0019985183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist