Healthcare Provider Details

I. General information

NPI: 1255945465
Provider Name (Legal Business Name): BLAKE HERSCHBERGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2765 NW 49TH AVE UNIT 301
OCALA FL
34482-6215
US

IV. Provider business mailing address

2765 NW 49TH AVE UNIT 301
OCALA FL
34482-6215
US

V. Phone/Fax

Practice location:
  • Phone: 352-401-3606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS61520
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: