Provider Demographics
NPI:1396186151
Name:NELSON, JACOB C (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:C
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-0719
Mailing Address - Country:US
Mailing Address - Phone:218-485-4401
Mailing Address - Fax:218-485-8774
Practice Address - Street 1:441 ARROWHEAD LN
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-7702
Practice Address - Country:US
Practice Address - Phone:218-485-4401
Practice Address - Fax:218-485-8774
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120004183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist