Provider Demographics
NPI:1437431848
Name:SHELLY, JON MICHAEL (RPH)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:MICHAEL
Last Name:SHELLY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-3628
Mailing Address - Country:US
Mailing Address - Phone:330-497-8316
Mailing Address - Fax:330-494-8236
Practice Address - Street 1:1000 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-3628
Practice Address - Country:US
Practice Address - Phone:330-497-8316
Practice Address - Fax:330-494-8236
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03209239183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist