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NPI Code Detail

MEDICARE: BLAKE EVANS GROGAN PHARM.D

MEDICARE: BLAKE EVANS GROGAN PHARM.D
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183500000XPharmacist5351016688MI

General Provider Information

NPI Number : 1114543667
Entity Type Code : Individual
Provider Name (Legal Business Name) : BLAKE EVANS GROGAN PHARM.D
Provider Business Mailing Address
First Line : 5100 E BELTLINE AVE NE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49525-1006
Country : US
Telephone Number : 616-361-1758
Fax Number :
Provider Business Practice Location Address
First Line : 5100 E BELTLINE AVE NE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49525-1006
Country : US
Telephone Number : 616-361-1758
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/21/2020
Last Update Date : 06/21/2020

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Directions to “ BLAKE EVANS GROGAN PHARM.D” Practice Location

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