Provider Demographics
NPI:1043207491
Name:BLAKE PHARMACY INC.
Entity type:Organization
Organization Name:BLAKE PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/MGR.
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:APPLEGATE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:937-587-3100
Mailing Address - Street 1:103 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PEEBLES
Mailing Address - State:OH
Mailing Address - Zip Code:45660-1246
Mailing Address - Country:US
Mailing Address - Phone:937-587-3100
Mailing Address - Fax:937-587-5045
Practice Address - Street 1:103 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PEEBLES
Practice Address - State:OH
Practice Address - Zip Code:45660-1246
Practice Address - Country:US
Practice Address - Phone:937-587-3100
Practice Address - Fax:937-587-5045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3634208OtherNABP
OH0315297Medicaid