Provider Demographics
NPI:1104107432
Name:JACOBS, MATTHEW (RPH)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 WABASHA ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1108
Mailing Address - Country:US
Mailing Address - Phone:651-224-6030
Mailing Address - Fax:
Practice Address - Street 1:425 WABASHA ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1108
Practice Address - Country:US
Practice Address - Phone:651-224-6030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1146620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1146620OtherPHARMACY LICENSE