Provider Demographics
NPI:1952028714
Name:JACOBSEN, BRYCE ANTON (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:ANTON
Last Name:JACOBSEN
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 1:46822 W RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-3583
Mailing Address - Country:US
Mailing Address - Phone:586-383-3731
Mailing Address - Fax:
Practice Address - Street 1:30055 NORTHWESTERN HWY STE 225
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3231
Practice Address - Country:US
Practice Address - Phone:865-377-0248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302414689183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist