Provider Demographics
NPI:1407465834
Name:MARTINEZ, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MARTINEZ
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 1:17238 BULVERDE RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-2401
Mailing Address - Country:US
Mailing Address - Phone:210-495-0572
Mailing Address - Fax:
Practice Address - Street 1:17238 BULVERDE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-2401
Practice Address - Country:US
Practice Address - Phone:210-495-0572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67003183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist