Provider Demographics
NPI:1740765882
Name:LILLY, JACOB ROSS (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ROSS
Last Name:LILLY
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 1:252 RURAL ACRES DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3503
Mailing Address - Country:US
Mailing Address - Phone:304-252-8324
Mailing Address - Fax:
Practice Address - Street 1:252 RURAL ACRES DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3503
Practice Address - Country:US
Practice Address - Phone:304-252-8324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVRP0007913OtherPHARMACIST LICENSE