Provider Demographics
NPI:1093317315
Name:LAWYER, BLANE
Entity Type:Individual
Prefix:
First Name:BLANE
Middle Name:
Last Name:LAWYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ODON
Mailing Address - State:IN
Mailing Address - Zip Code:47562-1218
Mailing Address - Country:US
Mailing Address - Phone:812-636-4609
Mailing Address - Fax:812-636-8004
Practice Address - Street 1:200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ODON
Practice Address - State:IN
Practice Address - Zip Code:47562-1218
Practice Address - Country:US
Practice Address - Phone:812-636-4609
Practice Address - Fax:812-636-8004
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026671A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100294700Medicaid