Provider Demographics
NPI:1255626065
Name:BAREFOOT, BLAKE GRIMES (RPH)
Entity type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:GRIMES
Last Name:BAREFOOT
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 1:5167 NICHOLAS CRK
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-2356
Mailing Address - Country:US
Mailing Address - Phone:910-452-7587
Mailing Address - Fax:910-395-0749
Practice Address - Street 1:4711 NEW CENTRE DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3442
Practice Address - Country:US
Practice Address - Phone:910-395-0749
Practice Address - Fax:910-395-0749
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND12093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist