Provider Demographics
NPI:1043207772
Name:SHAH, JAYANT S (RPH)
Entity Type:Individual
Prefix:MR
First Name:JAYANT
Middle Name:S
Last Name:SHAH
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 1:1941 E 173RD PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-3733
Mailing Address - Country:US
Mailing Address - Phone:773-264-1111
Mailing Address - Fax:
Practice Address - Street 1:11309 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4911
Practice Address - Country:US
Practice Address - Phone:773-264-1111
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist