Provider Demographics
NPI:1023303682
Name:BROCKWELL, ROBERT BLAKE
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BLAKE
Last Name:BROCKWELL
Suffix:
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 1:22218 N 1750 EAST RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61834-7456
Mailing Address - Country:US
Mailing Address - Phone:217-260-0688
Mailing Address - Fax:
Practice Address - Street 1:22218 N 1750 EAST RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61834-7456
Practice Address - Country:US
Practice Address - Phone:217-260-0688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-12
Last Update Date:2011-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087172183500000X
IL049.160038183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No183500000XPharmacy Service ProvidersPharmacist