Provider Demographics
NPI:1750675534
Name:LEWIS, JACOB MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MICHAEL
Last Name:LEWIS
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 1:113 STAR GRASS STE 100
Mailing Address - Street 2:
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070
Mailing Address - Country:US
Mailing Address - Phone:830-214-2920
Mailing Address - Fax:
Practice Address - Street 1:113 STAR GRASS STE 100
Practice Address - Street 2:
Practice Address - City:SPRING BRANCH
Practice Address - State:TX
Practice Address - Zip Code:78070
Practice Address - Country:US
Practice Address - Phone:830-214-2920
Practice Address - Fax:830-214-2953
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46279183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist