Healthcare Provider Details

I. General information

NPI: 1679193684
Provider Name (Legal Business Name): GREGORY MICHAEL BLAKE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 SE SALERNO RD
STUART FL
34997-6503
US

IV. Provider business mailing address

544 SW KABOT AVE
PORT SAINT LUCIE FL
34953-3053
US

V. Phone/Fax

Practice location:
  • Phone: 772-223-2300
  • Fax:
Mailing address:
  • Phone: 772-626-4362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License NumberPS58228
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: