Provider Demographics
NPI:1528349115
Name:SHALLON, JEROME J (RPH)
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:J
Last Name:SHALLON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12095 S OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9763
Mailing Address - Country:US
Mailing Address - Phone:219-365-7232
Mailing Address - Fax:708-891-2426
Practice Address - Street 1:626 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5712
Practice Address - Country:US
Practice Address - Phone:708-891-0039
Practice Address - Fax:708-891-2426
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-031785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist