Provider Demographics
NPI:1043828163
Name:EDWARDS, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:EDWARDS
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:PO BOX 167
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:KS
Mailing Address - Zip Code:67554-0167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:921 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:KS
Practice Address - Zip Code:67554-1708
Practice Address - Country:US
Practice Address - Phone:620-509-2169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-1058941835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist