Provider Demographics
NPI:1255974499
Name:BLAKE, SAMANTHA PAIGE (RPH)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:PAIGE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 WOODMAN DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1423
Mailing Address - Country:US
Mailing Address - Phone:937-256-1901
Mailing Address - Fax:
Practice Address - Street 1:146 WOODMAN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45431-1423
Practice Address - Country:US
Practice Address - Phone:937-256-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03439216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist