Provider Demographics
NPI:1215025002
Name:SHAW, ROBERT THOMAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:THOMAS
Last Name:SHAW
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 1:219 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARISSA
Mailing Address - State:IL
Mailing Address - Zip Code:62257-1343
Mailing Address - Country:US
Mailing Address - Phone:618-295-2241
Mailing Address - Fax:618-295-3669
Practice Address - Street 1:219 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARISSA
Practice Address - State:IL
Practice Address - Zip Code:62257-1343
Practice Address - Country:US
Practice Address - Phone:618-295-2241
Practice Address - Fax:618-295-3669
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1424504OtherNAPB NUMBER
IL371089281001Medicaid
ILAS9106558OtherDEA NUMBER
IL0286520001Medicare NSC