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General NPI Number Information
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NPI Number | 1316714926
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Entity Type | Individual
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Provider Name | JACOB SCIVALLY
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Gender | Male
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Dates
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Enumeration Date | 12/05/2023
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Last Update Date | 12/05/2023
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Provider Practice Location Address
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Address Line | 301 N WASHINGTON AVE
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City | DALLAS
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State | TX
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Zip | 75246-1754
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Country | US
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Telephone | 254-202-1272
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Fax | 469-800-8335
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Provider Business Mailing Address
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Address Line | 1400 ANDREWS PKWY APT 2124
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City | ALLEN
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State | TX
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Zip | 75002-2961
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Country | US
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Telephone | 469-268-0635
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Fax | 469-800-8335
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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 | 200639
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License Number State | TX
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