Basic Information
| Provider Information | |||||||||
| NPI: | 1023130556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | CARY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38060 MALLORY DR | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481541110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346448910 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2001 S MERRIMAN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WESTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481865539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347271040 | ||||||||
| FaxNumber: | 7347271037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5302021045 | MI | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.