Provider Demographics
NPI:1679842546
Name:JOHN, JISMOL SHIBY
Entity Type:Individual
Prefix:
First Name:JISMOL
Middle Name:SHIBY
Last Name:JOHN
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 1:363 GARDENIA DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-4442
Mailing Address - Country:US
Mailing Address - Phone:781-420-6710
Mailing Address - Fax:
Practice Address - Street 1:440 BLOSSOM HILL RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-1608
Practice Address - Country:US
Practice Address - Phone:408-448-2503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59386183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist