Provider Demographics
NPI:1669247490
Name:WASSOM, BLAKE (PHARMD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:WASSOM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4402
Mailing Address - Country:US
Mailing Address - Phone:210-358-4000
Mailing Address - Fax:
Practice Address - Street 1:5282 MEDICAL DR STE 250
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6039
Practice Address - Country:US
Practice Address - Phone:972-644-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX671461835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care