Provider Demographics
NPI:1124340575
Name:JACOB, JOE
Entity type:Individual
Prefix:MR
First Name:JOE
Middle Name:
Last Name:JACOB
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 1:703 NEWBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:N BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-1613
Mailing Address - Country:US
Mailing Address - Phone:516-409-9442
Mailing Address - Fax:516-409-4126
Practice Address - Street 1:703 NEWBRIDGE RD
Practice Address - Street 2:
Practice Address - City:N BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-1613
Practice Address - Country:US
Practice Address - Phone:516-409-9442
Practice Address - Fax:516-409-4126
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI037661-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist