Provider Demographics
NPI:1518636877
Name:GREENWALD, JACOB AARON (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:AARON
Last Name:GREENWALD
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 1:17 SHERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:CT
Mailing Address - Zip Code:06447-1457
Mailing Address - Country:US
Mailing Address - Phone:860-614-6240
Mailing Address - Fax:
Practice Address - Street 1:619 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-2011
Practice Address - Country:US
Practice Address - Phone:413-271-9990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH240327183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist