=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144044488
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAKE MERRICK TRAVIS PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2024
-----------------------------------------------------
Last Update Date | 01/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4815 N ASSEMBLY ST
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99205-6185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-495-2490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 384
-----------------------------------------------------
City | NINE MILE FALLS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99026-0384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-495-2490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 7171175
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PH70007545
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------