Provider Demographics
NPI:1871627901
Name:BLAKE, JANE ANN (RPH)
Entity type:Individual
Prefix:MS
First Name:JANE
Middle Name:ANN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:14705 WESTERLY PL
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7918
Mailing Address - Country:US
Mailing Address - Phone:636-391-3562
Mailing Address - Fax:
Practice Address - Street 1:3023 N BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2330
Practice Address - Country:US
Practice Address - Phone:314-996-7501
Practice Address - Fax:314-996-7502
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0423211835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric