Provider Demographics
NPI:1598209843
Name:SHAH, GUNJAN
Entity Type:Individual
Prefix:
First Name:GUNJAN
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2844 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6017
Mailing Address - Country:US
Mailing Address - Phone:773-687-4513
Mailing Address - Fax:773-687-4514
Practice Address - Street 1:2844 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6017
Practice Address - Country:US
Practice Address - Phone:773-687-4513
Practice Address - Fax:773-687-4514
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051294370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist