Provider Demographics
NPI:1013518877
Name:MATLOCK, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MATLOCK
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 1:479745 E 1100 RD
Mailing Address - Street 2:
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954-5069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2425 S ZERO ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-8663
Practice Address - Country:US
Practice Address - Phone:479-646-4983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD11121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist