Provider Demographics
NPI:1780049783
Name:SHEDLOCK, DELYNN
Entity type:Individual
Prefix:
First Name:DELYNN
Middle Name:
Last Name:SHEDLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 US 31 S
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4520
Mailing Address - Country:US
Mailing Address - Phone:231-995-0207
Mailing Address - Fax:231-995-0226
Practice Address - Street 1:2401 US 31 S
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4520
Practice Address - Country:US
Practice Address - Phone:231-995-0207
Practice Address - Fax:231-995-0226
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029247183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1902823123Medicare UPIN