Provider Demographics
NPI:1801232947
Name:LEGACY PHARM VENTURES LLC
Entity Type:Organization
Organization Name:LEGACY PHARM VENTURES LLC
Other - Org Name:JACOBS FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-647-7093
Mailing Address - Street 1:2701 AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801-5834
Mailing Address - Country:US
Mailing Address - Phone:325-646-1100
Mailing Address - Fax:325-646-1104
Practice Address - Street 1:2701 AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-5834
Practice Address - Country:US
Practice Address - Phone:325-646-2322
Practice Address - Fax:325-646-2322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX285543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138803OtherPK