Provider Demographics
NPI:1518236801
Name:BLANCO, JAMES M (RPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:BLANCO
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 1:10732 MARTINIQUE LN
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-9448
Mailing Address - Country:US
Mailing Address - Phone:219-663-4557
Mailing Address - Fax:
Practice Address - Street 1:10732 MARTINIQUE LN
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-9448
Practice Address - Country:US
Practice Address - Phone:219-663-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26013507183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist