Provider Demographics
NPI:1164774071
Name:JACOB, MARY (RPH)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 S WAUKEGAN RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5216
Mailing Address - Country:US
Mailing Address - Phone:847-498-4151
Mailing Address - Fax:847-498-9864
Practice Address - Street 1:16 S WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-5216
Practice Address - Country:US
Practice Address - Phone:847-498-4151
Practice Address - Fax:847-498-9864
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040128183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist