Provider Demographics
NPI:1568761815
Name:FOOTE, SHELLY
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:FOOTE
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 1:141 WHITE HORSE DR
Mailing Address - Street 2:
Mailing Address - City:NEW CASTE
Mailing Address - State:CO
Mailing Address - Zip Code:81647
Mailing Address - Country:US
Mailing Address - Phone:615-522-8037
Mailing Address - Fax:
Practice Address - Street 1:1320 RAILROAD AVE.
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650
Practice Address - Country:US
Practice Address - Phone:970-625-9420
Practice Address - Fax:970-625-6185
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16360183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist