Healthcare Provider Details

I. General information

NPI: 1417830811
Provider Name (Legal Business Name): BEAU BLAKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2025
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4602 EASTPARK BLVD
MADISON WI
53718-2002
US

IV. Provider business mailing address

1010 E WASHINGTON AVE APT 1019
MADISON WI
53703-4414
US

V. Phone/Fax

Practice location:
  • Phone: 608-440-6400
  • Fax:
Mailing address:
  • Phone: 262-995-5275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number22042
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: