MEDICARE: MR. BRIAN THOMAS JACOBS R.PH.

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	5302020331	MI

General Provider Information

NPI Number	:	1669771341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN THOMAS JACOBS R.PH.

Provider Business Mailing Address
First Line	:	4515 E MOUNT MORRIS RD
Second Line	:
City	:	MOUNT MORRIS
State	:	MI
Zip	:	48458-8737
Country	:	US
Telephone Number	:	810-640-2110
Fax Number	:	810-640-1560

Provider Business Practice Location Address
First Line	:	4515 E MOUNT MORRIS RD
Second Line	:
City	:	MOUNT MORRIS
State	:	MI
Zip	:	48458-8737
Country	:	US
Telephone Number	:	810-640-2110
Fax Number	:	810-640-1560

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

Provider Enumeration Date	:	03/21/2011
Last Update Date	:	03/21/2011

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