Provider Demographics
NPI:1083332118
Name:HIGGINBOTHAM, JACOB ANTHONY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ANTHONY
Last Name:HIGGINBOTHAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 TUCKER STATION RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-4546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2611 TUCKER STATION RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-4546
Practice Address - Country:US
Practice Address - Phone:941-962-3566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029902A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist