Provider Demographics
NPI:1598158651
Name:SHORTER, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SHORTER
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 1:1507 ODELL AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-2604
Mailing Address - Country:US
Mailing Address - Phone:865-471-0366
Mailing Address - Fax:865-471-3612
Practice Address - Street 1:1507 ODELL AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2604
Practice Address - Country:US
Practice Address - Phone:865-471-0366
Practice Address - Fax:865-471-3612
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36074183500000X
NC22114183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist