Provider Demographics
NPI:1508525627
Name:SMITH, BLAINE TEMPLAR (RPH, PHD)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:TEMPLAR
Last Name:SMITH
Suffix:
Gender:M
Credentials:RPH, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12032 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-5910
Mailing Address - Country:US
Mailing Address - Phone:405-735-3950
Mailing Address - Fax:
Practice Address - Street 1:12032 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-5910
Practice Address - Country:US
Practice Address - Phone:405-735-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11002183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist