Provider Demographics
NPI:1790176006
Name:TANG, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:TANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940SE 12TH, NO. 9
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:503-231-1043
Mailing Address - Fax:
Practice Address - Street 1:1940 SE 12TH AVE APT 9
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4779
Practice Address - Country:US
Practice Address - Phone:503-231-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR67881835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist