Provider Demographics
NPI:1639112998
Name:SHELLYS MEDICATION SERVICES, INC
Entity Type:Organization
Organization Name:SHELLYS MEDICATION SERVICES, INC
Other - Org Name:SHELLYS MEDICATION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP MARKETING
Authorized Official - Prefix:
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:
Authorized Official - Last Name:SPOON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH BSC FASCP
Authorized Official - Phone:215-785-6616
Mailing Address - Street 1:2522 PEARL BUCK RD
Mailing Address - Street 2:UNIT A
Mailing Address - City:BRISTOL
Mailing Address - State:PA
Mailing Address - Zip Code:19007-6809
Mailing Address - Country:US
Mailing Address - Phone:218-785-6616
Mailing Address - Fax:215-781-6020
Practice Address - Street 1:2522 PEARL BUCK RD UNIT A
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007-6809
Practice Address - Country:US
Practice Address - Phone:218-785-6616
Practice Address - Fax:215-781-6020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP414479L3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012553540003Medicaid
2080954OtherPK
2080954OtherPK