Provider Demographics
NPI:1811000144
Name:BLAKE PHARMACY
Entity Type:Organization
Organization Name:BLAKE PHARMACY
Other - Org Name:BLAKE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/MGR
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-587-3100
Mailing Address - Street 1:103 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PEEBLES
Mailing Address - State:OH
Mailing Address - Zip Code:45660-1246
Mailing Address - Country:US
Mailing Address - Phone:937-587-3100
Mailing Address - Fax:937-587-5045
Practice Address - Street 1:103 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PEEBLES
Practice Address - State:OH
Practice Address - Zip Code:45660-1246
Practice Address - Country:US
Practice Address - Phone:937-587-3100
Practice Address - Fax:937-587-5045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0223686003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2143874OtherPK
OH0315297Medicaid
OH5554450001Medicare NSC