Basic Information
| Provider Information | |||||||||
| NPI: | 1285833459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUSMAK | ||||||||
| FirstName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1310 W 22ND ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053288600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 04/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 5144 | SD | N | Pharmacy Service Providers | Pharmacist | 207N00000X | PENDING | SD | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.