Provider Demographics
NPI:1275925471
Name:JACOB, TINU ELSA (RPH)
Entity Type:Individual
Prefix:
First Name:TINU
Middle Name:ELSA
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 1:9117 SARANAC TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76118-7702
Mailing Address - Country:US
Mailing Address - Phone:262-501-2360
Mailing Address - Fax:
Practice Address - Street 1:2253 CENTRAL DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5834
Practice Address - Country:US
Practice Address - Phone:817-868-9202
Practice Address - Fax:817-868-9207
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist