Healthcare Provider Details

I. General information

NPI: 1811145436
Provider Name (Legal Business Name): BLAIRCO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N AUGUSTA CT STE 103
MANKATO MN
56001-7720
US

IV. Provider business mailing address

120 N AUGUSTA CT STE 103
MANKATO MN
56001-7720
US

V. Phone/Fax

Practice location:
  • Phone: 507-345-4302
  • Fax: 507-387-2917
Mailing address:
  • Phone: 507-345-4302
  • Fax: 507-387-2917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number263083
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier263083
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMN BOARD OF PHARMACY

VIII. Authorized Official

Name: DR. BRENT E BLAIR
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 507-345-4302