Provider Demographics
NPI:1508950916
Name:KEITH A SHELTON
Entity Type:Organization
Organization Name:KEITH A SHELTON
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-686-7216
Mailing Address - Street 1:200 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-4856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 N 10TH ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4856
Practice Address - Country:US
Practice Address - Phone:573-686-7216
Practice Address - Fax:573-686-7217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO332B00000X
MO004034333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO621708502Medicaid
MO601708506Medicaid
2619231OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2619231OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MO0884750001Medicare NSC