Basic Information
| Provider Information | |||||||||
| NPI: | 1215525605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAM | ||||||||
| FirstName: | MAN KUNG JAMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14777 DRAYTON DR | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460628260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595396226 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5550 E FALL CREEK PARKWAY NORTH DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462261453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176144051 | ||||||||
| FaxNumber: | 3176144052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2021 | ||||||||
| LastUpdateDate: | 01/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 018038 | KY | N | Pharmacy Service Providers | Pharmacist | 183500000X | 051.302967 | IL | N | Pharmacy Service Providers | Pharmacist | 183500000X | 26026304A | IN | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.