Provider Demographics
NPI:1639623390
Name:SHAW, DUSTIN (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2788 VAUGHNS GROVE FAIRVW RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:KY
Mailing Address - Zip Code:42266-9713
Mailing Address - Country:US
Mailing Address - Phone:270-839-2226
Mailing Address - Fax:
Practice Address - Street 1:320 W 18TH ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1965
Practice Address - Country:US
Practice Address - Phone:270-887-0166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist