Provider Demographics
NPI:1164504148
Name:BLAKELY, THOMAS J (RPH/DPH)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:RPH/DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4990 W MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:MC NEAL
Mailing Address - State:AZ
Mailing Address - Zip Code:85617-9653
Mailing Address - Country:US
Mailing Address - Phone:520-533-2520
Mailing Address - Fax:520-533-0464
Practice Address - Street 1:2240 WINROW AVE
Practice Address - Street 2:USA MEDDAC, RWBAHC
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613
Practice Address - Country:US
Practice Address - Phone:520-533-2520
Practice Address - Fax:520-533-0464
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9196183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist