Provider Demographics
NPI:1043744634
Name:BLANCO, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BLANCO
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 1:600 PLANTATION ISLAND DR S
Mailing Address - Street 2:UNIT 3
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6010
Mailing Address - Country:US
Mailing Address - Phone:904-461-1081
Mailing Address - Fax:904-461-1082
Practice Address - Street 1:600 PLANTATION ISLAND DR S
Practice Address - Street 2:UNIT 3
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6010
Practice Address - Country:US
Practice Address - Phone:904-461-1081
Practice Address - Fax:904-461-1082
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS34155183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist