Provider Demographics
NPI:1467134635
Name:CANNESTRA, JACOB THOMAS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:THOMAS
Last Name:CANNESTRA
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 1:1524 BIG BEND RD UNIT J
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-7660
Mailing Address - Country:US
Mailing Address - Phone:414-581-2807
Mailing Address - Fax:
Practice Address - Street 1:21325 E MORELAND BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2909
Practice Address - Country:US
Practice Address - Phone:262-798-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22272-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist