Provider Demographics
NPI:1508041948
Name:JACOB, DIANA (RPH)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3203
Mailing Address - Country:US
Mailing Address - Phone:631-549-9400
Mailing Address - Fax:631-549-1190
Practice Address - Street 1:391 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3203
Practice Address - Country:US
Practice Address - Phone:631-549-9400
Practice Address - Fax:631-549-1190
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050815183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist