Provider Demographics
NPI:1487733390
Name:SHAW, JEAN ROSS
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:ROSS
Last Name:SHAW
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 1:12401 HIGHWAY 491 S
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MS
Mailing Address - Zip Code:39365-8540
Mailing Address - Country:US
Mailing Address - Phone:601-656-5477
Mailing Address - Fax:601-650-9882
Practice Address - Street 1:584 E MAIN ST
Practice Address - Street 2:SUITE8-A
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2342
Practice Address - Country:US
Practice Address - Phone:601-656-5477
Practice Address - Fax:601-650-9882
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSN/A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0040112Medicaid
MS0040112Medicaid