Provider Demographics
NPI:1861028292
Name:JOSEPH, SHOBIN CHUMMAR
Entity Type:Individual
Prefix:
First Name:SHOBIN
Middle Name:CHUMMAR
Last Name:JOSEPH
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 1:744 N CLARK ST APT 802
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-7396
Mailing Address - Country:US
Mailing Address - Phone:847-858-6753
Mailing Address - Fax:
Practice Address - Street 1:744 N CLARK ST APT 802
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-7396
Practice Address - Country:US
Practice Address - Phone:847-858-6753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1915240183500000X
IL051301268183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist