Provider Demographics
NPI:1811145436
Name:BLAIRCO, INC.
Entity type:Organization
Organization Name:BLAIRCO, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:507-345-4302
Mailing Address - Street 1:120 N AUGUSTA CT STE 103
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-7720
Mailing Address - Country:US
Mailing Address - Phone:507-345-4302
Mailing Address - Fax:507-387-2917
Practice Address - Street 1:120 N AUGUSTA CT STE 103
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-7720
Practice Address - Country:US
Practice Address - Phone:507-345-4302
Practice Address - Fax:507-387-2917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2630833336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN263083OtherMN BOARD OF PHARMACY
FT0732998OtherDEA