Provider Demographics
NPI:1932537727
Name:SHALLAL, PAUL GEORGE
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:GEORGE
Last Name:SHALLAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:GEORGE
Other - Last Name:SHALLAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:504 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-5600
Mailing Address - Country:US
Mailing Address - Phone:248-225-9919
Mailing Address - Fax:
Practice Address - Street 1:504 MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-5600
Practice Address - Country:US
Practice Address - Phone:248-225-9919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-15
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038880183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist