=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215525605
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAN KUNG JAMES SHAM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2021
-----------------------------------------------------
Last Update Date | 01/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5550 E FALL CREEK PARKWAY NORTH DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46226-1453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-614-4051
-----------------------------------------------------
Fax | 317-614-4052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14777 DRAYTON DR
-----------------------------------------------------
City | NOBLESVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46062-8260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-539-6226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 018038
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051.302967
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26026304A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------