Provider Demographics
NPI:1053923284
Name:PULICKIEL, SHAJAN JOSEPH
Entity type:Individual
Prefix:
First Name:SHAJAN
Middle Name:JOSEPH
Last Name:PULICKIEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10626 FARMERSVILLE FRK
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-2597
Mailing Address - Country:US
Mailing Address - Phone:954-612-5278
Mailing Address - Fax:
Practice Address - Street 1:10626 FARMERSVILLE FRK
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-2597
Practice Address - Country:US
Practice Address - Phone:954-612-5278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60182183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist