Provider Demographics
NPI:1629441316
Name:SUTHERLAND, JACOB M (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:M
Last Name:SUTHERLAND
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 1:7025 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1664
Mailing Address - Country:US
Mailing Address - Phone:414-203-0683
Mailing Address - Fax:
Practice Address - Street 1:7025 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-1664
Practice Address - Country:US
Practice Address - Phone:414-203-0683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18085-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist