Provider Demographics
NPI:1346844198
Name:BOWERSOCK, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BOWERSOCK
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 1:2117 KELLE DR APT 104
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8986
Mailing Address - Country:US
Mailing Address - Phone:419-204-9672
Mailing Address - Fax:
Practice Address - Street 1:901 N KARWICK RD
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-2191
Practice Address - Country:US
Practice Address - Phone:219-872-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024687A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26024687AOtherPHARMACIST