Provider Demographics
NPI:1619222890
Name:CRISP, JACOB D (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:D
Last Name:CRISP
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 1:3510 S LORETTA DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-5974
Mailing Address - Country:US
Mailing Address - Phone:509-496-6093
Mailing Address - Fax:
Practice Address - Street 1:120 N PINE ST
Practice Address - Street 2:SUITE 156
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-5029
Practice Address - Country:US
Practice Address - Phone:509-343-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60167773183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist