Provider Demographics
NPI:1750127056
Name:SOWARDS, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:SOWARDS
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 1:16482 STATE HIGHWAY 136
Mailing Address - Street 2:
Mailing Address - City:LA JARA
Mailing Address - State:CO
Mailing Address - Zip Code:81140-9473
Mailing Address - Country:US
Mailing Address - Phone:195-804-5707
Mailing Address - Fax:
Practice Address - Street 1:106 BLANCA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2340
Practice Address - Country:US
Practice Address - Phone:719-587-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-05
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17096183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist