Provider Demographics
NPI:1114521275
Name:JACOB, ROSILY J
Entity Type:Individual
Prefix:
First Name:ROSILY
Middle Name:J
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 1:1109 GLEN PARK LN
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-5112
Mailing Address - Country:US
Mailing Address - Phone:813-956-6704
Mailing Address - Fax:
Practice Address - Street 1:4005 US HIGHWAY 98 N
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-3815
Practice Address - Country:US
Practice Address - Phone:863-815-9408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0031680183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist