Provider Demographics
NPI:1851698955
Name:SHEPHERD, DUSTIN R
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:R
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6742 CABLE CAR LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-3629
Mailing Address - Country:US
Mailing Address - Phone:304-312-3630
Mailing Address - Fax:
Practice Address - Street 1:131 RACINE DR STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8781
Practice Address - Country:US
Practice Address - Phone:910-784-9545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21405183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist