Provider Demographics
NPI:1912275108
Name:SHACKELFORD, TONYA (BS)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 NEW GETWELL RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-6801
Mailing Address - Country:US
Mailing Address - Phone:901-238-3784
Mailing Address - Fax:901-284-0123
Practice Address - Street 1:4300 NEW GETWELL RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-6801
Practice Address - Country:US
Practice Address - Phone:901-238-3784
Practice Address - Fax:901-284-0123
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11494183500000X
OK11729183500000X
AR2011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist