Provider Demographics
NPI:1962783621
Name:KALATHIVEETIL, JACOB R (BS IN PHARMACY)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:R
Last Name:KALATHIVEETIL
Suffix:
Gender:M
Credentials:BS IN PHARMACY
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Other - First Name:
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Mailing Address - Street 1:1926 W 35TH ST
Mailing Address - Street 2:WALGREENS
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1204
Mailing Address - Country:US
Mailing Address - Phone:773-254-5523
Mailing Address - Fax:773-254-9537
Practice Address - Street 1:1926 W 35TH ST
Practice Address - Street 2:WALGREENS
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-1204
Practice Address - Country:US
Practice Address - Phone:773-254-5523
Practice Address - Fax:773-254-9537
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL051030494183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist