Provider Demographics
NPI:1376289470
Name:SHACKELFORD, CHRISTOPHER JARVENE (RPH)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JARVENE
Last Name:SHACKELFORD
Suffix:
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:PO BOX 439
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-0439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7122 WILL ROBBINS HWY
Practice Address - Street 2:
Practice Address - City:NETTLETON
Practice Address - State:MS
Practice Address - Zip Code:38858-5918
Practice Address - Country:US
Practice Address - Phone:662-591-5234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08819183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist