Provider Demographics
NPI:1023392131
Name:BOREK, JAKUB
Entity Type:Individual
Prefix:
First Name:JAKUB
Middle Name:
Last Name:BOREK
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 1:1064 MCCAUSLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1925
Mailing Address - Country:US
Mailing Address - Phone:708-743-9893
Mailing Address - Fax:
Practice Address - Street 1:1225 UNION BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-1519
Practice Address - Country:US
Practice Address - Phone:314-367-8211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009023426183500000X
IL051293737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist