Provider Demographics
NPI:1184894156
Name:SHAATAL, JONATHAN R (MS, RPH)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:R
Last Name:SHAATAL
Suffix:
Gender:M
Credentials:MS, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 E 96TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3903
Mailing Address - Country:US
Mailing Address - Phone:718-688-8755
Mailing Address - Fax:
Practice Address - Street 1:1222 E 96TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3903
Practice Address - Country:US
Practice Address - Phone:718-688-8755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-06
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02829849Medicaid
NY6130060001Medicare NSC