Provider Demographics
NPI:1467743849
Name:BLAKE, MALLORY ORLANDO (RPH)
Entity Type:Individual
Prefix:MR
First Name:MALLORY
Middle Name:ORLANDO
Last Name:BLAKE
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 1:345 S CLOVERDALE AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3409
Mailing Address - Country:US
Mailing Address - Phone:323-933-3006
Mailing Address - Fax:
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-4506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist