Healthcare Provider Details

I. General information

NPI: 1902032535
Provider Name (Legal Business Name): JACOB A MOCK PHARMD, BCGP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAKE A MOCK PHARMD

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 03/29/2021
Certification Date: 03/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 CENTRAL AVE
EIELSON AFB AK
99702-2301
US

IV. Provider business mailing address

1650 COWLES ST FAIRBANKS MEMORIAL HOSPITAL
FAIRBANKS AK
99701
US

V. Phone/Fax

Practice location:
  • Phone: 907-377-6606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number102058
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH-0013183
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: