MEDICARE: JAINI JACOB

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RP445989	PA

General Provider Information

NPI Number	:	1225441421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAINI JACOB

Provider Business Mailing Address
First Line	:	8130 ROOSEVELT BLVD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-2911
Country	:	US
Telephone Number	:	215-331-0160
Fax Number	:

Provider Business Practice Location Address
First Line	:	8130 ROOSEVELT BLVD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-2911
Country	:	US
Telephone Number	:	215-331-0160
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2014
Last Update Date	:	06/05/2014

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