Provider Demographics
NPI:1700068012
Name:SHAW PHARMACY
Entity Type:Organization
Organization Name:SHAW PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-295-2241
Mailing Address - Street 1:219 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARISSA
Mailing Address - State:IL
Mailing Address - Zip Code:62257-1343
Mailing Address - Country:US
Mailing Address - Phone:618-295-2241
Mailing Address - Fax:618-295-3669
Practice Address - Street 1:219 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARISSA
Practice Address - State:IL
Practice Address - Zip Code:62257-1343
Practice Address - Country:US
Practice Address - Phone:618-295-2241
Practice Address - Fax:618-295-3669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1424504OtherNABP NUMBER
ILAS9106558OtherDEA NUMBER
IL=========001Medicaid
IL1424504OtherNABP NUMBER