Provider Demographics
NPI:1780681023
Name:BLAKE, NATHAN THOMAS (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:THOMAS
Last Name:BLAKE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 145TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-6240
Mailing Address - Country:US
Mailing Address - Phone:612-483-6781
Mailing Address - Fax:
Practice Address - Street 1:2500 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-1909
Practice Address - Country:US
Practice Address - Phone:612-721-1611
Practice Address - Fax:612-721-1611
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118039-8183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist