MEDICARE: JACOB COFFMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PD15393	AR

General Provider Information

NPI Number	:	1215539804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB COFFMAN

Provider Business Mailing Address
First Line	:	905 HEMBREE AVE
Second Line	:
City	:	SPRINGDALE
State	:	AR
Zip	:	72764-6976
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8600 HIGHWAY 71 S # SS
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72908-8042
Country	:	US
Telephone Number	:	479-289-6898
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2020
Last Update Date	:	11/10/2020

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Directions to “ JACOB COFFMAN ” Practice Location

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