Provider Demographics
NPI:1861836462
Name:BUFFAT, BLAKE J (PHARMD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:J
Last Name:BUFFAT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 VERN ST
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1627
Mailing Address - Country:US
Mailing Address - Phone:208-241-2475
Mailing Address - Fax:
Practice Address - Street 1:550 VERN ST
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-1627
Practice Address - Country:US
Practice Address - Phone:208-241-2475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6419183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist