Provider Demographics
NPI:1821873654
Name:BOURNE, JOSEPH BLAKE III
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:BLAKE
Last Name:BOURNE
Suffix:III
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 1:1801 YORK RD
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-5119
Mailing Address - Country:US
Mailing Address - Phone:443-470-4050
Mailing Address - Fax:443-470-4056
Practice Address - Street 1:1801 YORK RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-5119
Practice Address - Country:US
Practice Address - Phone:443-470-4050
Practice Address - Fax:443-470-4056
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD29390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist