Provider Demographics
NPI:1619256286
Name:DALLAS, JACOB (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:DALLAS
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 1:1100 N PRIEST DR
Mailing Address - Street 2:APT. 2024
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-1004
Mailing Address - Country:US
Mailing Address - Phone:314-805-7586
Mailing Address - Fax:
Practice Address - Street 1:705 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2519
Practice Address - Country:US
Practice Address - Phone:602-258-4865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018634183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist