Healthcare Provider Details

I. General information

NPI: 1871627901
Provider Name (Legal Business Name): JANE ANN BLAKE R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 N BALLAS RD
SAINT LOUIS MO
63131-2330
US

IV. Provider business mailing address

14705 WESTERLY PL
CHESTERFIELD MO
63017-7918
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-7501
  • Fax: 314-996-7502
Mailing address:
  • Phone: 636-391-3562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number042321
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: