Provider Demographics
NPI:1336739663
Name:SUTHERLAND, SHAD J (RPH)
Entity Type:Individual
Prefix:
First Name:SHAD
Middle Name:J
Last Name:SUTHERLAND
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 1:415 POLIE HANDY RD
Mailing Address - Street 2:
Mailing Address - City:CANMER
Mailing Address - State:KY
Mailing Address - Zip Code:42722-9445
Mailing Address - Country:US
Mailing Address - Phone:404-824-0187
Mailing Address - Fax:
Practice Address - Street 1:1028 N DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2508
Practice Address - Country:US
Practice Address - Phone:270-982-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY018449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist