Healthcare Provider Details

I. General information

NPI: 1912084351
Provider Name (Legal Business Name): SHELLEE A GRIM PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST ROOM C300
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

833 S WOOD ST ROOM 164 MC 886
CHICAGO IL
60612-7229
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-3663
  • Fax: 312-413-4146
Mailing address:
  • Phone: 312-996-0870
  • Fax: 312-996-0379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number012149
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00040273
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number051.289617
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: