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General NPI Number Information
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NPI Number | 1346844198
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Entity Type | Individual
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Provider Name | JACOB BOWERSOCK
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Gender | Male
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Dates
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Enumeration Date | 11/23/2020
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Last Update Date | 11/23/2020
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Provider Practice Location Address
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Address Line | 901 N KARWICK RD
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City | MICHIGAN CITY
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State | IN
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Zip | 46360-2191
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Country | US
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Telephone | 219-872-6811
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Fax |
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Provider Business Mailing Address
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Address Line | 2117 KELLE DR APT 104
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City | CHESTERTON
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State | IN
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Zip | 46304-8986
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Country | US
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Telephone | 419-204-9672
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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 | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 26024687A
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License Number State | IN
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