Provider Demographics
NPI:1407442817
Name:BUSCH, BLAKE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:BUSCH
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 1:5770 WICKERSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-7236
Mailing Address - Country:US
Mailing Address - Phone:314-445-9615
Mailing Address - Fax:
Practice Address - Street 1:8450 EAGER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-1413
Practice Address - Country:US
Practice Address - Phone:314-962-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051303232183500000X
MO2019025919183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist