Healthcare Provider Details

I. General information

NPI: 1093328734
Provider Name (Legal Business Name): BLAKE DESOUSA PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3848 FALMOUTH RD
MARSTONS MILLS MA
02648-5707
US

IV. Provider business mailing address

3848 FALMOUTH RD
MARSTONS MILLS MA
02648-5707
US

V. Phone/Fax

Practice location:
  • Phone: 508-428-3525
  • Fax:
Mailing address:
  • Phone: 508-428-3525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH239386
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: