Provider Demographics
NPI:1790193910
Name:SHAH, JAINAM
Entity Type:Individual
Prefix:
First Name:JAINAM
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 E 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2402
Mailing Address - Country:US
Mailing Address - Phone:586-755-3046
Mailing Address - Fax:586-755-4348
Practice Address - Street 1:1921 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2402
Practice Address - Country:US
Practice Address - Phone:586-755-3046
Practice Address - Fax:586-755-4348
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042476183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist