Provider Demographics
NPI:1376129676
Name:JUSTUS, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JUSTUS
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 1:606 WINTHROP CT
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:OH
Mailing Address - Zip Code:44839-1468
Mailing Address - Country:US
Mailing Address - Phone:419-602-3871
Mailing Address - Fax:
Practice Address - Street 1:3700 MILAN RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5618
Practice Address - Country:US
Practice Address - Phone:419-625-0733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03439301183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist