Provider Demographics
NPI:1467193359
Name:BLANCK, LEVI RUSSELL (PHARMD)
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:RUSSELL
Last Name:BLANCK
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 1:1611 S BALTIMORE ST STE B
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4521
Mailing Address - Country:US
Mailing Address - Phone:660-956-7010
Mailing Address - Fax:660-956-7015
Practice Address - Street 1:12521 W 97TH TER APT 100
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-1517
Practice Address - Country:US
Practice Address - Phone:913-680-7112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021030845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist