Provider Demographics
NPI:1225623226
Name:HINSON, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:HINSON
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 1:156 FROEMMING RD
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-8462
Mailing Address - Country:US
Mailing Address - Phone:337-462-0177
Mailing Address - Fax:
Practice Address - Street 1:18507 JOHNNY B HALL MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:ROSEPINE
Practice Address - State:LA
Practice Address - Zip Code:70659
Practice Address - Country:US
Practice Address - Phone:337-462-0177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0234611835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty