Provider Demographics
NPI:1508273376
Name:JACOB, TRAVIS DAVID (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:DAVID
Last Name:JACOB
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-5801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321
Practice Address - Country:US
Practice Address - Phone:219-836-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRPH. 03234093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist