Healthcare Provider Details

I. General information

NPI: 1760363436
Provider Name (Legal Business Name): SHADDI JUAN JAIME MEJIA MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S 99TH AVE
TOLLESON AZ
85353-9700
US

IV. Provider business mailing address

12806 N 130TH LN
EL MIRAGE AZ
85335-2211
US

V. Phone/Fax

Practice location:
  • Phone: 623-925-0851
  • Fax:
Mailing address:
  • Phone: 602-300-9874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberS027673
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: