Provider Demographics
NPI:1013528710
Name:SHAFFER, JACOB S (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:S
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 HOOVER AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-5246
Mailing Address - Country:US
Mailing Address - Phone:937-263-2836
Mailing Address - Fax:937-263-2952
Practice Address - Street 1:4121 HOOVER AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-5246
Practice Address - Country:US
Practice Address - Phone:937-263-2836
Practice Address - Fax:937-263-2952
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03438931183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist