Provider Demographics
NPI:1184224149
Name:STEFAN, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:STEFAN
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 1:6244 WILMINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-7024
Mailing Address - Country:US
Mailing Address - Phone:937-848-3218
Mailing Address - Fax:
Practice Address - Street 1:6244 WILMINGTON PIKE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-7024
Practice Address - Country:US
Practice Address - Phone:937-848-3218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03124731183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist