Provider Demographics
NPI:1457481400
Name:JACOBS, MARK R (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:JACOBS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2761 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2246
Mailing Address - Country:US
Mailing Address - Phone:608-365-4418
Mailing Address - Fax:
Practice Address - Street 1:2761 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2246
Practice Address - Country:US
Practice Address - Phone:608-365-4418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist