Provider Demographics
NPI:1083914691
Name:JACOB, RANDALL CHARLES
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:CHARLES
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 1:1505 HIGHWAY 43 S
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-9297
Mailing Address - Country:US
Mailing Address - Phone:601-889-9509
Mailing Address - Fax:
Practice Address - Street 1:1505 HIGHWAY 43 S
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-9297
Practice Address - Country:US
Practice Address - Phone:601-889-9509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13751183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist