Provider Demographics
NPI:1760826994
Name:TESFAMARIAM, JACOB W (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:W
Last Name:TESFAMARIAM
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 1:3249 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-5210
Mailing Address - Country:US
Mailing Address - Phone:646-641-0666
Mailing Address - Fax:
Practice Address - Street 1:10 SNYDER AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2700
Practice Address - Country:US
Practice Address - Phone:215-465-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP446883183500000X
NJ28RI03503900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist