Healthcare Provider Details

I. General information

NPI: 1285300277
Provider Name (Legal Business Name): JACOB REYES PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 MONCLOVA RD
MAUMEE OH
43537-1841
US

IV. Provider business mailing address

380 MIAMI ST
TIFFIN OH
44883-2050
US

V. Phone/Fax

Practice location:
  • Phone: 419-893-5911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03440923
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: