Provider Demographics
NPI:1790845170
Name:JACOBSON, HOWARD (RPH)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HEMPSTEAD AVE
Mailing Address - Street 2:SUITE 156
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4033
Mailing Address - Country:US
Mailing Address - Phone:516-459-5009
Mailing Address - Fax:516-678-3246
Practice Address - Street 1:30 HEMPSTEAD AVE
Practice Address - Street 2:SUITE 156
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4033
Practice Address - Country:US
Practice Address - Phone:516-459-5009
Practice Address - Fax:516-678-3246
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032536183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY032536OtherPHARMACIST LICENSE