Provider Demographics
NPI:1245548098
Name:SHORES, WYLIE LEE (RPH)
Entity type:Individual
Prefix:
First Name:WYLIE
Middle Name:LEE
Last Name:SHORES
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 1:6145 RIPPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-9586
Mailing Address - Country:US
Mailing Address - Phone:318-518-0359
Mailing Address - Fax:
Practice Address - Street 1:745 SHREVEPORT BARKSDALE HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2201
Practice Address - Country:US
Practice Address - Phone:318-861-3985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13028183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA13028OtherPHARMACY LICENSE