Healthcare Provider Details

I. General information

NPI: 1871180760
Provider Name (Legal Business Name): JACLYN MICHELLE SHORE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2020
Last Update Date: 12/25/2020
Certification Date: 12/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 BETHLEHEM PIKE
ERDENHEIM PA
19038-7702
US

IV. Provider business mailing address

420 W LANCASTER AVE
DEVON PA
19333-1510
US

V. Phone/Fax

Practice location:
  • Phone: 215-233-4485
  • Fax:
Mailing address:
  • Phone: 215-876-0420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP445657
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: