Provider Demographics
NPI:1710694625
Name:BLAND, CHARLENE JAYNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:JAYNE
Last Name:BLAND
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 PROSPECT AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1139
Mailing Address - Country:US
Mailing Address - Phone:626-200-8200
Mailing Address - Fax:
Practice Address - Street 1:122 W 146TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10039-3802
Practice Address - Country:US
Practice Address - Phone:212-675-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI069512183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist