Provider Demographics
NPI:1467042481
Name:JAKUBOSKI, THOMAS ANTHONY (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ANTHONY
Last Name:JAKUBOSKI
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 1:15 OAK GROVE LN
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-2292
Mailing Address - Country:US
Mailing Address - Phone:636-248-2371
Mailing Address - Fax:
Practice Address - Street 1:890 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1416
Practice Address - Country:US
Practice Address - Phone:636-248-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-23
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041798183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO041798OtherMISSOURI REGISTERED PHARMACIST LICENSE