Provider Demographics
NPI:1548734098
Name:GODFREY, SHELBY LYNN
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LYNN
Last Name:GODFREY
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 1:1002 SALEM CHIPLEY RD
Mailing Address - Street 2:
Mailing Address - City:PINE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:31822-4614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1905 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1649
Practice Address - Country:US
Practice Address - Phone:706-295-7787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12433390200000X
GARPH033118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program