Provider Demographics
NPI:1376147488
Name:ROOT, SHELTON LUCIAN IV (RPH)
Entity Type:Individual
Prefix:
First Name:SHELTON
Middle Name:LUCIAN
Last Name:ROOT
Suffix:IV
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 1:2823 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-1619
Mailing Address - Country:US
Mailing Address - Phone:540-949-8871
Mailing Address - Fax:540-949-7934
Practice Address - Street 1:2823 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-1619
Practice Address - Country:US
Practice Address - Phone:540-949-8871
Practice Address - Fax:540-949-7934
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031927183500000X
VA0202215106183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist