Provider Demographics
NPI:1700090461
Name:SHAW, BRIAN JAMES (PHARMD, CGP)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:SHAW
Suffix:
Gender:M
Credentials:PHARMD, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 BREUINGTON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-8102
Mailing Address - Country:US
Mailing Address - Phone:731-414-1206
Mailing Address - Fax:
Practice Address - Street 1:708 W FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3901
Practice Address - Country:US
Practice Address - Phone:731-425-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN116951835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric