Provider Demographics
NPI:1134004179
Name:WANG, JACOB (PHARMD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WANG
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 1:22 MARIE ALICIA DR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-2442
Mailing Address - Country:US
Mailing Address - Phone:978-727-4996
Mailing Address - Fax:
Practice Address - Street 1:6 QUEEN ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-2146
Practice Address - Country:US
Practice Address - Phone:203-426-2595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-08
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0017086183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist