Provider Demographics
NPI:1063016327
Name:SHAW, JEREMY SLADE
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:SLADE
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 N SAM HOUSTON PKWY E
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-2900
Mailing Address - Country:US
Mailing Address - Phone:281-454-0101
Mailing Address - Fax:
Practice Address - Street 1:8000 N SAM HOUSTON PKWY E
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-2900
Practice Address - Country:US
Practice Address - Phone:281-454-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39061183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist