Provider Demographics
NPI:1902411382
Name:FLORES, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:FLORES
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 1:1300 HWY 290 W
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:TX
Mailing Address - Zip Code:78621-1400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 HWY 290 W
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:TX
Practice Address - Zip Code:78621-1400
Practice Address - Country:US
Practice Address - Phone:512-285-5552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist