Provider Demographics
NPI:1649745324
Name:LI, JAKE (RPH)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 OLD FARM RD APT 928
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-4436
Mailing Address - Country:US
Mailing Address - Phone:281-451-9481
Mailing Address - Fax:
Practice Address - Street 1:2500 OLD FARM RD #928
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-7706
Practice Address - Country:US
Practice Address - Phone:281-451-9481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist