Healthcare Provider Details

I. General information

NPI: 1205402856
Provider Name (Legal Business Name): JACOB AARON BOAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 E OHIO ST
CLINTON MO
64735-2402
US

IV. Provider business mailing address

902 WILLOW ST
CLINTON MO
64735-3058
US

V. Phone/Fax

Practice location:
  • Phone: 660-890-2587
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2019034275
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: