Healthcare Provider Details

I. General information

NPI: 1174512289
Provider Name (Legal Business Name): ELIZABETH W. BLAKE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 SUMTER ST ROOM 314A
COLUMBIA SC
29208-0001
US

IV. Provider business mailing address

156 PRESQUE ISLE RD
LEXINGTON SC
29072-7746
US

V. Phone/Fax

Practice location:
  • Phone: 803-777-6058
  • Fax: 803-777-1943
Mailing address:
  • Phone: 803-808-7227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number10123
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: