Healthcare Provider Details

I. General information

NPI: 1619222890
Provider Name (Legal Business Name): JACOB D CRISP PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N PINE ST SUITE 156
SPOKANE WA
99202-5029
US

IV. Provider business mailing address

3510 S LORETTA DR
SPOKANE VALLEY WA
99206-5974
US

V. Phone/Fax

Practice location:
  • Phone: 509-343-3400
  • Fax:
Mailing address:
  • Phone: 509-496-6093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH 60167773
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: