Healthcare Provider Details

I. General information

NPI: 1881205433
Provider Name (Legal Business Name): JACOB THOMAS HOFERER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2020
Last Update Date: 08/16/2020
Certification Date: 08/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E FREEDOM WAY UNIT 410
CINCINNATI OH
45202-3453
US

IV. Provider business mailing address

120 E FREEDOM WAY UNIT 410
CINCINNATI OH
45202-3453
US

V. Phone/Fax

Practice location:
  • Phone: 513-404-1723
  • Fax:
Mailing address:
  • Phone: 513-404-1723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number021526
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number03440060
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: