=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376540971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAY B.B. BLAKE PHARM.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1611 NW 12TH AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33136-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-585-7195
-----------------------------------------------------
Fax | 305-585-0088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1560 NW 15TH TER
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33030-2828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-243-3756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P1200X
-----------------------------------------------------
Taxonomy Name | Pharmacotherapy Pharmacist
-----------------------------------------------------
License Number | PS31499
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------