Healthcare Provider Details

I. General information

NPI: 1770867889
Provider Name (Legal Business Name): JACOB BALYEAT PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 RANDALLIA DR
FORT WAYNE IN
46805-4638
US

IV. Provider business mailing address

2200 RANDALLIA DR
FORT WAYNE IN
46805-4638
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-3430
  • Fax:
Mailing address:
  • Phone: 260-373-3430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26023313A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: