Provider Demographics
NPI:1467722975
Name:MIRSKY, BLAKE RYAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:RYAN
Last Name:MIRSKY
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 1:1403 VIOLA DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1403 VIOLA DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7326
Practice Address - Country:US
Practice Address - Phone:813-503-2835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-31
Last Update Date:2011-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 48176183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist