Provider Demographics
NPI:1922081736
Name:BLAKE, CHARLES R (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:R
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 1:456 FAIR PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:OH
Mailing Address - Zip Code:45693-1057
Mailing Address - Country:US
Mailing Address - Phone:937-544-2037
Mailing Address - Fax:
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:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-06698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist