Provider Demographics
NPI:1366038788
Name:KENNEDY, BLAKE THOMAS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:THOMAS
Last Name:KENNEDY
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 1:826 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-1435
Mailing Address - Country:US
Mailing Address - Phone:269-967-5121
Mailing Address - Fax:
Practice Address - Street 1:826 N PINE ST
Practice Address - Street 2:
Practice Address - City:ISHPEMING
Practice Address - State:MI
Practice Address - Zip Code:49849-1435
Practice Address - Country:US
Practice Address - Phone:269-967-5121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041893183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist