Provider Demographics
NPI:1780937276
Name:JACOB, VIKKI LYNN (RPH)
Entity type:Individual
Prefix:
First Name:VIKKI
Middle Name:LYNN
Last Name:JACOB
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 WILLOW OAK CIR NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-1748
Mailing Address - Country:US
Mailing Address - Phone:423-476-2512
Mailing Address - Fax:
Practice Address - Street 1:5380 HIGHWAY 153
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4946
Practice Address - Country:US
Practice Address - Phone:423-870-8562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-21
Last Update Date:2012-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8008183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist