Provider Demographics
NPI:1174737258
Name:SHAW, JACOB JOHNSTON
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JOHNSTON
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 HUTCH MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-8707
Mailing Address - Country:US
Mailing Address - Phone:828-692-4266
Mailing Address - Fax:
Practice Address - Street 1:605 5TH AVE W
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28739-4205
Practice Address - Country:US
Practice Address - Phone:828-692-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist