Provider Demographics
NPI:1538417084
Name:COTTAM, JACOB (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:COTTAM
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 1:3475 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6781
Mailing Address - Country:US
Mailing Address - Phone:208-227-5083
Mailing Address - Fax:208-227-5087
Practice Address - Street 1:3475 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6781
Practice Address - Country:US
Practice Address - Phone:208-227-5083
Practice Address - Fax:208-227-5087
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist