Healthcare Provider Details

I. General information

NPI: 1376540971
Provider Name (Legal Business Name): JAY B.B. BLAKE PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1560 NW 15TH TER
HOMESTEAD FL
33030-2828
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-7195
  • Fax: 305-585-0088
Mailing address:
  • Phone: 786-243-3756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPS31499
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: