Provider Demographics
NPI:1891117735
Name:JACOB'S DISCOUNT PHARMACY, INC.
Entity Type:Organization
Organization Name:JACOB'S DISCOUNT PHARMACY, INC.
Other - Org Name:JACOB'S DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAGAE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOAWAD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:412-799-3943
Mailing Address - Street 1:8118 LONG POINT RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-2006
Mailing Address - Country:US
Mailing Address - Phone:713-469-3502
Mailing Address - Fax:713-469-3505
Practice Address - Street 1:8118 LONG POINT RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-2006
Practice Address - Country:US
Practice Address - Phone:713-469-3502
Practice Address - Fax:713-469-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-13
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX287353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143730OtherPK
TX146896Medicaid