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General NPI Number Information
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NPI Number | 1275102204
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Entity Type | Individual
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Provider Name | JACOB WARREN CPHT
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Gender | Male
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Dates
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Enumeration Date | 06/23/2021
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Last Update Date | 06/23/2021
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Provider Practice Location Address
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Address Line | 2629 N PARK DR
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City | HOLLAND
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State | MI
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Zip | 49424-8503
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Country | US
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Telephone | 616-393-8071
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Fax |
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Provider Business Mailing Address
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Address Line | 8710 SAND WEDGE TRL
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City | WEST OLIVE
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State | MI
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Zip | 49460-8524
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183700000X
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Taxonomy Name | Pharmacy Technician
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License Number | 19214080842
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License Number State | MI
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