Provider Demographics
NPI:1558967638
Name:LAIRD, JACOB CHARLES (PHARMD,RPH)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:CHARLES
Last Name:LAIRD
Suffix:
Gender:M
Credentials:PHARMD,RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W GRAND AVE APT 1707
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-5809
Mailing Address - Country:US
Mailing Address - Phone:330-635-6311
Mailing Address - Fax:
Practice Address - Street 1:3001 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4843
Practice Address - Country:US
Practice Address - Phone:847-406-2261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.303661183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist