Provider Demographics
NPI:1639613441
Name:HENNING, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:HENNING
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 1:26615 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:NE
Mailing Address - Zip Code:68064-4472
Mailing Address - Country:US
Mailing Address - Phone:402-488-1184
Mailing Address - Fax:
Practice Address - Street 1:5625 O ST STE 101
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2104
Practice Address - Country:US
Practice Address - Phone:402-488-1184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13367183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist