Provider Demographics
NPI:1497339485
Name:TETRAULT, JACOB W (PHARMD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:W
Last Name:TETRAULT
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 1:5 WALKER ST STE 1
Mailing Address - Street 2:
Mailing Address - City:LENOX
Mailing Address - State:MA
Mailing Address - Zip Code:01240-2723
Mailing Address - Country:US
Mailing Address - Phone:413-637-4700
Mailing Address - Fax:413-637-0366
Practice Address - Street 1:5 WALKER ST STE 1
Practice Address - Street 2:
Practice Address - City:LENOX
Practice Address - State:MA
Practice Address - Zip Code:01240-2723
Practice Address - Country:US
Practice Address - Phone:413-637-4700
Practice Address - Fax:413-637-0366
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH238588183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist