=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467134635
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB THOMAS CANNESTRA PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2023
-----------------------------------------------------
Last Update Date | 08/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21325 E MORELAND BLVD
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53186-2909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-798-0223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1524 BIG BEND RD UNIT J
-----------------------------------------------------
City | WAUKESHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53189-7660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-581-2807
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 22272-40
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------