Provider Demographics
NPI:1407032147
Name:SHAH, JAINEN (RPH)
Entity Type:Individual
Prefix:MR
First Name:JAINEN
Middle Name:
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 1:5105 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-3511
Mailing Address - Country:US
Mailing Address - Phone:718-240-9924
Mailing Address - Fax:
Practice Address - Street 1:5105 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3511
Practice Address - Country:US
Practice Address - Phone:718-240-9924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist