Provider Demographics
NPI:1497450605
Name:SMITH, JACOB RYAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:SMITH
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 1:10065 PARADISE LN
Mailing Address - Street 2:
Mailing Address - City:BAY SAINT LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-8995
Mailing Address - Country:US
Mailing Address - Phone:573-778-8882
Mailing Address - Fax:
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39534-2508
Practice Address - Country:US
Practice Address - Phone:228-376-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-100251183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist