Provider Demographics
NPI:1356097588
Name:BLAKE, MARTHA (RPH)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
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 1:1550 SE FLORESTA DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-4069
Mailing Address - Country:US
Mailing Address - Phone:772-340-4142
Mailing Address - Fax:772-785-5753
Practice Address - Street 1:17269 ORANGE BLVD
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-6056
Practice Address - Country:US
Practice Address - Phone:561-888-2766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS27541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist