Provider Demographics
NPI:1093315624
Name:CRAWFORD, JACOB M (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:M
Last Name:CRAWFORD
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 1:4606 E 12TH ST UNIT 4
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-6785
Mailing Address - Country:US
Mailing Address - Phone:440-759-0116
Mailing Address - Fax:
Practice Address - Street 1:2304 E LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5416
Practice Address - Country:US
Practice Address - Phone:307-635-0241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist