Provider Demographics
NPI:1225354483
Name:JACOB, SAM K
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:K
Last Name:JACOB
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:SAM
Other - Middle Name:K
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:12117 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2524
Mailing Address - Country:US
Mailing Address - Phone:718-849-9800
Mailing Address - Fax:718-849-9801
Practice Address - Street 1:12117 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2524
Practice Address - Country:US
Practice Address - Phone:718-849-9800
Practice Address - Fax:718-849-9801
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054266183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist