Provider Demographics
NPI:1043841075
Name:JACOB, SHERMIE
Entity Type:Individual
Prefix:
First Name:SHERMIE
Middle Name:
Last Name:JACOB
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 1:295 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-2738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:295 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-2738
Practice Address - Country:US
Practice Address - Phone:248-814-6521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042438183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist