Provider Demographics
NPI:1316522402
Name:SANDERS, JACOB CODY
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:CODY
Last Name:SANDERS
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 1:1005 ARLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4036
Mailing Address - Country:US
Mailing Address - Phone:580-272-0283
Mailing Address - Fax:
Practice Address - Street 1:1005 ARLINGTON ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4036
Practice Address - Country:US
Practice Address - Phone:580-272-0283
Practice Address - Fax:580-272-0281
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19160183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist