Provider Demographics
NPI:1114543667
Name:GROGAN, BLAKE EVANS (PHARMD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:EVANS
Last Name:GROGAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 E BELTLINE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1006
Mailing Address - Country:US
Mailing Address - Phone:616-361-1758
Mailing Address - Fax:
Practice Address - Street 1:5100 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1006
Practice Address - Country:US
Practice Address - Phone:616-361-1758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-21
Last Update Date:2020-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5351016688183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist