Provider Demographics
NPI:1023593662
Name:JACOBI, BRANDON (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:JACOBI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N SYCAMORE AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-8895
Mailing Address - Country:US
Mailing Address - Phone:402-415-4693
Mailing Address - Fax:
Practice Address - Street 1:1705 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-1873
Practice Address - Country:US
Practice Address - Phone:575-323-9001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-29
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008992183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty