Provider Demographics
NPI:1477815868
Name:SHAKAMAK HEALTH INC
Entity Type:Organization
Organization Name:SHAKAMAK HEALTH INC
Other - Org Name:SHAKAMAK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:TRAVER
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-665-9760
Mailing Address - Street 1:346 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JASONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47438-1510
Mailing Address - Country:US
Mailing Address - Phone:812-665-9760
Mailing Address - Fax:812-665-9762
Practice Address - Street 1:346 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JASONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47438-1510
Practice Address - Country:US
Practice Address - Phone:812-665-9760
Practice Address - Fax:812-665-9762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IN60006304A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201070090Medicaid
2134527OtherPK