Provider Demographics
NPI:1285024166
Name:BLANCKE, ANN
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:BLANCKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 AVENIDA DE LAS BRISAS
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-8602
Mailing Address - Country:US
Mailing Address - Phone:707-541-7302
Mailing Address - Fax:
Practice Address - Street 1:16251 MAIN ST
Practice Address - Street 2:
Practice Address - City:GUERNEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95446-8300
Practice Address - Country:US
Practice Address - Phone:707-869-9055
Practice Address - Fax:707-869-9201
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43852183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist