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General NPI Number Information
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NPI Number | 1558967638
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Entity Type | Individual
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Provider Name | JACOB CHARLES LAIRD PHARMD,R.PH
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Gender | Male
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Dates
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Enumeration Date | 12/05/2020
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Last Update Date | 12/05/2020
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Provider Practice Location Address
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Address Line | 3001 WASHINGTON ST
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City | WAUKEGAN
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State | IL
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Zip | 60085-4843
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Country | US
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Telephone | 847-406-2261
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Fax |
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Provider Business Mailing Address
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Address Line | 330 W GRAND AVE APT 1707
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City | CHICAGO
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State | IL
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Zip | 60654-5809
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Country | US
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Telephone | 330-635-6311
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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 | 051.303661
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License Number State | IL
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