Provider Demographics
NPI:1023127248
Name:BALLARD, ROBERT SHANE (RPH)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:SHANE
Last Name:BALLARD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 MANORA ESTATES LN
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-8708
Mailing Address - Country:US
Mailing Address - Phone:205-759-1983
Mailing Address - Fax:205-553-9773
Practice Address - Street 1:4201 UNIVERSITY BLVD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-4403
Practice Address - Country:US
Practice Address - Phone:205-553-9477
Practice Address - Fax:205-553-9773
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist