Basic Information
| Provider Information | |||||||||
| NPI: | 1275925471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | TINU | ||||||||
| MiddleName: | ELSA | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9117 SARANAC TRL | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761187702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625012360 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2253 CENTRAL DR | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760215834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178689202 | ||||||||
| FaxNumber: | 8178689207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2015 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 56146 | TX | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.