Provider Demographics
NPI:1235779125
Name:IVEY, JACOB (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:IVEY
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11795 SONGBIRD RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-6877
Mailing Address - Country:US
Mailing Address - Phone:618-694-1075
Mailing Address - Fax:
Practice Address - Street 1:3333 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5884
Practice Address - Country:US
Practice Address - Phone:618-998-7821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013011981183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013011981OtherPHARMACIST
FLPS60361OtherPHARMACIST
IL051.291535OtherPHARMACIST