Provider Demographics
NPI:1760098172
Name:LANG, JACOB PHILLIP (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:PHILLIP
Last Name:LANG
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 1:9230 E BROADWAY RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-2426
Mailing Address - Country:US
Mailing Address - Phone:480-986-3004
Mailing Address - Fax:480-986-7039
Practice Address - Street 1:9230 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85208-2426
Practice Address - Country:US
Practice Address - Phone:480-986-3004
Practice Address - Fax:480-986-7039
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2023-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124728183500000X
AZS025208183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist