Healthcare Provider Details

I. General information

NPI: 1811000144
Provider Name (Legal Business Name): BLAKE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N MAIN ST
PEEBLES OH
45660-1246
US

IV. Provider business mailing address

103 N MAIN ST
PEEBLES OH
45660-1246
US

V. Phone/Fax

Practice location:
  • Phone: 937-587-3100
  • Fax: 937-587-5045
Mailing address:
  • Phone: 937-587-3100
  • Fax: 937-587-5045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number022368600
License Number StateOH

VIII. Authorized Official

Name: DUSTIN CAMPBELL
Title or Position: PHARMACIST/MGR
Credential:
Phone: 937-587-3100