Provider Demographics
NPI:1437866688
Name:SHAJU, SAMUEL KAROTTAKUTTU (PHARM D)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KAROTTAKUTTU
Last Name:SHAJU
Suffix:
Gender:M
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 1:8223 STATE HIGHWAY 151
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8223 STATE HIGHWAY 151
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-2104
Practice Address - Country:US
Practice Address - Phone:210-247-0017
Practice Address - Fax:210-301-4277
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68430183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist