Provider Demographics
NPI:1679193684
Name:BLAKE, GREGORY MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MICHAEL
Last Name:BLAKE
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 1:544 SW KABOT AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3053
Mailing Address - Country:US
Mailing Address - Phone:772-626-4362
Mailing Address - Fax:
Practice Address - Street 1:2100 SE SALERNO RD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6503
Practice Address - Country:US
Practice Address - Phone:772-223-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS582281835C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835C0205XPharmacy Service ProvidersPharmacistCritical Care