Provider Demographics
NPI:1518501642
Name:BENTLEY, BLAKE WELCH
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:WELCH
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 W 200 N
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-9711
Mailing Address - Country:US
Mailing Address - Phone:385-888-5320
Mailing Address - Fax:385-888-5325
Practice Address - Street 1:1370 W 200 N
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-9711
Practice Address - Country:US
Practice Address - Phone:385-888-5320
Practice Address - Fax:385-888-5325
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV18088183500000X
UT4898357-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist