Provider Demographics
NPI:1396227880
Name:DAUGHERTY, SHANE JOSEPH (RPH)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:JOSEPH
Last Name:DAUGHERTY
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 1:605 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:NEW STANTON
Mailing Address - State:PA
Mailing Address - Zip Code:15672-8701
Mailing Address - Country:US
Mailing Address - Phone:724-261-8378
Mailing Address - Fax:
Practice Address - Street 1:144 POST AVENUE
Practice Address - Street 2:
Practice Address - City:NEW STANTON
Practice Address - State:PA
Practice Address - Zip Code:15672
Practice Address - Country:US
Practice Address - Phone:724-925-9810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP452360183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist