Provider Demographics
NPI:1952688541
Name:BLEAK, ANDREW (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BLEAK
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 1:461 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5205
Mailing Address - Country:US
Mailing Address - Phone:435-590-3636
Mailing Address - Fax:
Practice Address - Street 1:702 W HOPI DR
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-2852
Practice Address - Country:US
Practice Address - Phone:928-524-2661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018540183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist