Provider Demographics
NPI:1720473135
Name:CONRAD, JACOB STEVEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:STEVEN
Last Name:CONRAD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 19TH ST SE
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-8270
Mailing Address - Country:US
Mailing Address - Phone:815-383-7720
Mailing Address - Fax:
Practice Address - Street 1:604 19TH ST SE
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-8270
Practice Address - Country:US
Practice Address - Phone:815-383-7720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL05129787183500000X
IN26025292A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist