Provider Demographics
NPI:1306405402
Name:BLAIS, LEO R (RPH)
Entity Type:Individual
Prefix:MR
First Name:LEO
Middle Name:R
Last Name:BLAIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 BANK ST
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-6162
Mailing Address - Country:US
Mailing Address - Phone:401-639-4903
Mailing Address - Fax:
Practice Address - Street 1:1137 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-2236
Practice Address - Country:US
Practice Address - Phone:602-169-0778
Practice Address - Fax:860-310-3294
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH02605183500000X
CTPCT.0014719183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist