Healthcare Provider Details

I. General information

NPI: 1962729566
Provider Name (Legal Business Name): KALEB WADE BLAIR PHARM.D., R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 04/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 ISOM PLAZA
ISOM KY
41824
US

IV. Provider business mailing address

PO BOX 250
ISOM KY
41824-0250
US

V. Phone/Fax

Practice location:
  • Phone: 606-633-9238
  • Fax: 606-633-0222
Mailing address:
  • Phone: 606-633-9238
  • Fax: 606-633-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number014012
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: