Provider Demographics
NPI:1417787730
Name:SHALLENBERGER, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:SHALLENBERGER
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 1:254 SHERATON WAY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-2383
Mailing Address - Country:US
Mailing Address - Phone:770-856-6740
Mailing Address - Fax:
Practice Address - Street 1:1727 MARS HILL RD NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-8090
Practice Address - Country:US
Practice Address - Phone:770-218-2426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH035037183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist