Healthcare Provider Details

I. General information

NPI: 1841942505
Provider Name (Legal Business Name): MR. JACOB ROBERT BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2574 EASTON ST NE
CANTON OH
44721-2662
US

IV. Provider business mailing address

2574 EASTON ST NE
CANTON OH
44721-2662
US

V. Phone/Fax

Practice location:
  • Phone: 330-492-6203
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number09214330
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number09318067
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: