Provider Demographics
NPI:1295002483
Name:TIBBE, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:TIBBE
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 1:494 BUTTERNUT DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-1556
Mailing Address - Country:US
Mailing Address - Phone:616-786-2235
Mailing Address - Fax:616-786-2237
Practice Address - Street 1:494 BUTTERNUT DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-1556
Practice Address - Country:US
Practice Address - Phone:616-786-2235
Practice Address - Fax:616-786-2237
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031477183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist