Provider Demographics
NPI:1487375986
Name:LECLAIRE, JACOB GRAY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:GRAY
Last Name:LECLAIRE
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 1:8237 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4004
Mailing Address - Country:US
Mailing Address - Phone:317-431-7757
Mailing Address - Fax:
Practice Address - Street 1:200 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:ATTICA
Practice Address - State:IN
Practice Address - Zip Code:47918-1313
Practice Address - Country:US
Practice Address - Phone:317-431-7757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029953A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist