Provider Demographics
NPI:1417268541
Name:DANIEL, D BLAKE (RPH)
Entity Type:Individual
Prefix:
First Name:D
Middle Name:BLAKE
Last Name:DANIEL
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 1:622 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4214
Mailing Address - Country:US
Mailing Address - Phone:770-227-7045
Mailing Address - Fax:770-227-8756
Practice Address - Street 1:622 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4214
Practice Address - Country:US
Practice Address - Phone:770-227-7045
Practice Address - Fax:770-227-8756
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016831183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7221950001Medicare NSC