Provider Demographics
NPI:1245830330
Name:SHAH, KULSOOM
Entity type:Individual
Prefix:
First Name:KULSOOM
Middle Name:
Last Name:SHAH
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 1:2601 MIDLAND DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8513
Mailing Address - Country:US
Mailing Address - Phone:773-987-7786
Mailing Address - Fax:
Practice Address - Street 1:2000 ORCHARD RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-1028
Practice Address - Country:US
Practice Address - Phone:630-844-3509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051294277183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist