Provider Demographics
NPI:1811664014
Name:SOUTH, JAKOB LARZ
Entity type:Individual
Prefix:
First Name:JAKOB
Middle Name:LARZ
Last Name:SOUTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 WOODDUCK DR SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-2672
Mailing Address - Country:US
Mailing Address - Phone:801-833-8090
Mailing Address - Fax:
Practice Address - Street 1:305 COOPER POINT RD NW STE 103
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4436
Practice Address - Country:US
Practice Address - Phone:360-754-8014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61179182183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty