Provider Demographics
NPI:1750167532
Name:BRAY, BLAKE (PHARMD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:BRAY
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 1:736 SEQUOIA WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-4471
Mailing Address - Country:US
Mailing Address - Phone:804-229-3434
Mailing Address - Fax:
Practice Address - Street 1:912 AIRLINE BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3309
Practice Address - Country:US
Practice Address - Phone:757-399-6361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist