Provider Demographics
NPI:1841473220
Name:JACOB, MINI (RPH)
Entity type:Individual
Prefix:
First Name:MINI
Middle Name:
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 1:11910 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-2002
Mailing Address - Country:US
Mailing Address - Phone:917-848-8439
Mailing Address - Fax:
Practice Address - Street 1:11910 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-2002
Practice Address - Country:US
Practice Address - Phone:718-835-2542
Practice Address - Fax:718-641-3044
Is Sole Proprietor?:No
Enumeration Date:2007-12-09
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045036-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00270439Medicaid