Provider Demographics
NPI:1003102765
Name:SHIMATA, JASON (PHARMD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SHIMATA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19610 SE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-7472
Mailing Address - Country:US
Mailing Address - Phone:360-258-6230
Mailing Address - Fax:360-258-6227
Practice Address - Street 1:19610 SE 1ST ST
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-7472
Practice Address - Country:US
Practice Address - Phone:360-258-6230
Practice Address - Fax:360-258-6227
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00061759183500000X
ORRPH-0010531183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist