Provider Demographics
NPI:1437412822
Name:JACOB, SANTOSH KURUVILLA
Entity Type:Individual
Prefix:MR
First Name:SANTOSH
Middle Name:KURUVILLA
Last Name:JACOB
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 1:104 MILITARY RD S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444
Mailing Address - Country:US
Mailing Address - Phone:253-538-1688
Mailing Address - Fax:
Practice Address - Street 1:104 MILITARY RD S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-6927
Practice Address - Country:US
Practice Address - Phone:253-538-1688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60090092183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist