Provider Demographics
NPI:1346845807
Name:SHEPHERD, PAIGE
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 BALLEK RD
Mailing Address - Street 2:
Mailing Address - City:RIEGELSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18077-9605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 WALMART PLZ
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NJ
Practice Address - Zip Code:08809-1264
Practice Address - Country:US
Practice Address - Phone:908-730-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP453134183500000X
NJ28RI03873300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0073296Medicaid