Provider Demographics
NPI:1063005734
Name:JACOB, ALIDA
Entity Type:Individual
Prefix:
First Name:ALIDA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4880 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:HILLTOP
Mailing Address - State:MN
Mailing Address - Zip Code:55421-2630
Mailing Address - Country:US
Mailing Address - Phone:763-571-7195
Mailing Address - Fax:
Practice Address - Street 1:4880 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:HILLTOP
Practice Address - State:MN
Practice Address - Zip Code:55421-2630
Practice Address - Country:US
Practice Address - Phone:763-571-7195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-14
Last Update Date:2021-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123692183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist