Provider Demographics
NPI:1285973982
Name:PALMER, JACOB GARRISON (PHARMD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:GARRISON
Last Name:PALMER
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 1:1201 COLOMBO AVE
Mailing Address - Street 2:APT. # 7103
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-5300
Mailing Address - Country:US
Mailing Address - Phone:608-886-3591
Mailing Address - Fax:
Practice Address - Street 1:4151 E HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2425
Practice Address - Country:US
Practice Address - Phone:520-452-7929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS019623183500000X
WI16942-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist