Provider Demographics
NPI:1720683667
Name:GRIFFIN, JAKE A (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:A
Last Name:GRIFFIN
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 1:5608 E CAPTAIN RD
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:IL
Mailing Address - Zip Code:61523-9276
Mailing Address - Country:US
Mailing Address - Phone:309-258-4372
Mailing Address - Fax:
Practice Address - Street 1:415 5TH ST
Practice Address - Street 2:
Practice Address - City:LACON
Practice Address - State:IL
Practice Address - Zip Code:61540-1211
Practice Address - Country:US
Practice Address - Phone:309-246-2555
Practice Address - Fax:309-246-2387
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295498183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist