Provider Demographics
NPI:1437444742
Name:SHACKELFORD, JILL RENEE (PHARM D)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:RENEE
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-6900
Mailing Address - Country:US
Mailing Address - Phone:248-608-0643
Mailing Address - Fax:
Practice Address - Street 1:1280 WALTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6900
Practice Address - Country:US
Practice Address - Phone:248-608-0643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS34998183500000X
MI5302031520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist