Provider Demographics
NPI:1760874135
Name:BLAKE, JOHN SCOTT (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:SCOTT
Last Name:BLAKE
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 1:624 TEXAS ST APT 403
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3553
Mailing Address - Country:US
Mailing Address - Phone:318-737-6999
Mailing Address - Fax:
Practice Address - Street 1:624 TEXAS ST APT 403
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3553
Practice Address - Country:US
Practice Address - Phone:318-737-6999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA300041835P0018X
LA0141001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist