Provider Demographics
NPI:1679806970
Name:REAVES, BLAKE
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:REAVES
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 1:215 WILLIAMSBORO ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27565-3330
Mailing Address - Country:US
Mailing Address - Phone:919-693-8801
Mailing Address - Fax:919-693-2401
Practice Address - Street 1:215 WILLIAMSBORO ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-3330
Practice Address - Country:US
Practice Address - Phone:919-693-8801
Practice Address - Fax:919-693-2401
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist