Provider Demographics
NPI:1669771341
Name:JACOBS, BRIAN THOMAS (RPH)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:THOMAS
Last Name:JACOBS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 E MOUNT MORRIS RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:MI
Mailing Address - Zip Code:48458-8737
Mailing Address - Country:US
Mailing Address - Phone:810-640-2110
Mailing Address - Fax:810-640-1560
Practice Address - Street 1:4515 E MOUNT MORRIS RD
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:MI
Practice Address - Zip Code:48458-8737
Practice Address - Country:US
Practice Address - Phone:810-640-2110
Practice Address - Fax:810-640-1560
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist