Provider Demographics
NPI:1114358835
Name:JACOB, STEVEN
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:STEVEN
Other - Middle Name:
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:5207 LAKE VENICE DR
Mailing Address - Street 2:
Mailing Address - City:WIMAUMA
Mailing Address - State:FL
Mailing Address - Zip Code:33598-4410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5207 LAKE VENICE DR
Practice Address - Street 2:
Practice Address - City:WIMAUMA
Practice Address - State:FL
Practice Address - Zip Code:33598-4410
Practice Address - Country:US
Practice Address - Phone:651-249-3727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS50681183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist