Provider Demographics
NPI:1265721773
Name:ILLINGWORTH, SHELLEY RENEE (RPH)
Entity type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:RENEE
Last Name:ILLINGWORTH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04462-1800
Mailing Address - Country:US
Mailing Address - Phone:207-723-9850
Mailing Address - Fax:
Practice Address - Street 1:2402 ROUTE 2 UNIT 1
Practice Address - Street 2:
Practice Address - City:HERMON
Practice Address - State:ME
Practice Address - Zip Code:04401-0665
Practice Address - Country:US
Practice Address - Phone:207-848-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4777183500000X
MAPH23998183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1265721773OtherNPI#