Provider Demographics
NPI:1235615378
Name:MAHR, JACOB THOMAS (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:MAHR
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:662 QUEENS CT
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-1608
Mailing Address - Country:US
Mailing Address - Phone:309-333-5931
Mailing Address - Fax:
Practice Address - Street 1:1501 CRESTON PARK DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-1151
Practice Address - Country:US
Practice Address - Phone:608-752-7431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051300216183500000X
WI19184-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist