Provider Demographics
NPI:1821371295
Name:RUSINSKI, JACOB (PHARM D)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:RUSINSKI
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LAKE HAVASU AVE S
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6565
Mailing Address - Country:US
Mailing Address - Phone:928-453-2808
Mailing Address - Fax:
Practice Address - Street 1:25 LAKE HAVASU AVE S
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6565
Practice Address - Country:US
Practice Address - Phone:928-453-2808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018798183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist