Provider Demographics
NPI:1821452368
Name:SHAW, JERRY (RPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:ALVARADO
Mailing Address - State:TX
Mailing Address - Zip Code:76009-3716
Mailing Address - Country:US
Mailing Address - Phone:817-783-2727
Mailing Address - Fax:817-783-2501
Practice Address - Street 1:208 N PARKWAY DR
Practice Address - Street 2:
Practice Address - City:ALVARADO
Practice Address - State:TX
Practice Address - Zip Code:76009-3716
Practice Address - Country:US
Practice Address - Phone:817-783-2727
Practice Address - Fax:817-783-2501
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist