Provider Demographics
NPI:1922557248
Name:FRUTCHEY, BLAKE (PHARMD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:FRUTCHEY
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 1:1027 16TH ST N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2877
Mailing Address - Country:US
Mailing Address - Phone:904-487-0069
Mailing Address - Fax:
Practice Address - Street 1:1027 16TH ST N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-2877
Practice Address - Country:US
Practice Address - Phone:904-487-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL43984183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist